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Harfouche MN, Kundi R, Scalea TM. Response to the letter to the editor for our article entitled "A Pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms?". J Trauma Acute Care Surg 2024:01586154-990000000-00702. [PMID: 38622768 DOI: 10.1097/ta.0000000000004360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Affiliation(s)
- Melike N Harfouche
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical System
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Harfouche MN, Kundi R, Scalea TM. Response to the letter to the editor for our article entitled "A Pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms?". J Trauma Acute Care Surg 2024:01586154-990000000-00697. [PMID: 38595222 DOI: 10.1097/ta.0000000000004359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Affiliation(s)
- Melike N Harfouche
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical System
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Rao AS, Scalea TM, Feliciano DV, Harfouche MN. More Harm Than Good: It is Time to Reconsider Prophylactic Fasciotomy in Lower-Extremity Vascular Injury. Am Surg 2024:31348241244629. [PMID: 38590003 DOI: 10.1177/00031348241244629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Four-compartment calf fasciotomy (CF) can be limb-saving. Prophylactic fasciotomy (PP) is advised in high-risk situations to prevent limb loss. Calf fasciotomy can cause significant morbidity, particularly if performed unnecessarily. We hypothesized that selective use of fasciotomies (SF) after lower-extremity vascular injury would lead to a lower rate of overall fasciotomies without an increase in limb complications than prophylactic fasciotomies (PFs). METHODS Trauma patients who sustained lower-extremity vascular injury that required operative repair at a high-volume trauma center were retrospectively reviewed and grouped by SF or PF (2016-2022). SF were individuals who were observed and underwent CF only if signs of compartment syndrome developed, whereas PF were individuals who underwent CF without signs of compartment syndrome. The primary outcome was amputation rate. Secondary outcomes were fasciotomy rate, need for reoperative vascular surgery, and clinical characteristics predisposing use of PF. RESULTS Of 101 overall patients, 30 patients (29.4%) had PF. Of the remaining 71 (SF group), 43.7% (n = 31) were spared CF. The median time from injury to vascular repair in both groups was the same (7 hours, P = .15). There was no difference in rate of vascular reoperation per group (PF = 26.7% vs SF = 23.9%, P = .77). The only clinical characteristic associated with PF was need for arterial shunt (OR 4.2, P = .028). CONCLUSIONS In trauma patients with lower-extremity vascular injury undergoing vascular repair, selective use of fasciotomy can spare almost half of patients the need for fasciotomy without an increase in limb complications.
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Treffalls RN, DuBose JJ, Brenner M, Piccinini A, Inaba K, Scalea TM, Moore LJ, Kauvar DS. Outcomes Associated With Aortic Balloon Occlusion Time in Patients With Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta. J Surg Res 2024; 296:256-264. [PMID: 38295713 DOI: 10.1016/j.jss.2023.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/08/2023] [Accepted: 12/29/2023] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) has the potential to cause clinically relevant systemic ischemic burden with long durations of aortic occlusion (AO). We aimed to examine the association between balloon occlusion time and clinical complications and mortality outcomes in patients undergoing zone 1 REBOA. METHODS A retrospective cohort analysis of American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acuteregistry patients with Zone 1 REBOA between 2013 and 2022 was performed. Patients with cardiopulmonary resuscitation on arrival or who did not survive past the emergency department were excluded. Total AO times were categorized as follows: <15 min, 15-30 min, 31-60 min, and >60 min. Clinical and procedural variables and in-hospital outcomes were compared across groups using bivariate and multivariate regression analyses. RESULTS There were 327 cases meeting inclusion criteria (n = 51 < 15 min, 83 15-30 min, 98 31-60 min, and 95 > 60 min, respectively). AO >60 min had higher admission lactate (8 ± 6; P = 0.004) compared to all other time groups, but injury severity score, heart rate, and systolic blood pressure were similar. Group average times from admission to definitive hemorrhage control ranged from 82 to 103 min and were similar across groups (85 min in AO >60 group). Longer AO times were associated with greater red blood cell, fresh frozen plasma transfusions (P < 0.001), and vasopressor use (P = 0.001). Mortality was greatest in the >60 min group (73%) versus the <15 min, 15-30 min, and 31-60 min groups (53%, 43%, and 45%, P < 0.001). With adjustment for injury severity score, systolic blood pressure, and lactate, AO >60 min had greater mortality (OR 3.7, 95% CI 1.6-9.4; P < 0.001) than other AO duration groups. Among 153 survivors, AO >60 min had a higher rate of multiple organ failure (15.4%) compared to the other AO durations (0%, 0%, and 4%, P = 0.02). There were no differences in amputation rates (0.7%) or spinal cord ischemia (1.4%). acute kidney injury was seen in 41% of >60 min versus 21%, 27%, and 33%, P = 0.42. CONCLUSIONS Though greater preocclusion physiologic injury may have been present, REBOA-induced ischemic insult was correlated with poor patient outcomes, specifically, REBOA inflation time >60 min had higher rates of mortality and multiple organ failure. Minimizing AO duration should be prioritized, and AO should not delay achieving definitive hemostasis. Partial REBOA may be a solution to extend safe AO time and deserves further study.
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Affiliation(s)
| | - Joseph J DuBose
- Department of Surgery, University of Texas Dell School of Medicine, Austin, Texas
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California
| | - Alice Piccinini
- Department of Surgery, Los Angelos County + University of Southern California Hospital, Los Angelos, California
| | - Kenji Inaba
- Department of Surgery, Los Angelos County + University of Southern California Hospital, Los Angelos, California
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Laura J Moore
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas
| | - David S Kauvar
- Vascular Surgery Service, Brooke Army Medical Center, Houston, Texas; Department of Surgery, Uniformed Services University, Bethesda, Maryland.
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Scalea TM, Shackford S, Schwab CW. In Memory of Dr. David Feliciano. J Trauma Acute Care Surg 2024:01586154-990000000-00663. [PMID: 38497940 DOI: 10.1097/ta.0000000000004323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
- Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | | | - C William Schwab
- Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
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Scalea TM. In memory of Dr David Feliciano. Trauma Surg Acute Care Open 2024; 9:e001383. [PMID: 38496775 PMCID: PMC10941138 DOI: 10.1136/tsaco-2024-001383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/19/2024] Open
Affiliation(s)
- Thomas M Scalea
- R Adams Cowly Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
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Richards JE, Stein DM, Scalea TM. Damage Control Resuscitation in Traumatic Hemorrhage: It Is More Than Fixing the Holes and Filling the Tank. Anesthesiology 2024; 140:586-598. [PMID: 37982159 DOI: 10.1097/aln.0000000000004750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Damage control resuscitation is the foundation of hemorrhagic shock management and includes early administration of plasma, tranexamic acid, and limited crystalloid-containing products.
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Affiliation(s)
- Justin E Richards
- Department of Anesthesiology, University of Maryland School of Medicine; Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Deborah M Stein
- Department of Surgery, University of Maryland School of Medicine; Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Thomas M Scalea
- Department of Surgery, University of Maryland School of Medicine; Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
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Austin SE, Galvagno SM, Podell JE, Teeter WA, Kundi R, Haase DJ, Taylor BS, Betzold R, Stein DM, Scalea TM, Powell EK. Venovenous extracorporeal membrane oxygenation in patients with traumatic brain injuries and severe respiratory failure: A single-center retrospective analysis. J Trauma Acute Care Surg 2024; 96:332-339. [PMID: 37828680 DOI: 10.1097/ta.0000000000004159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
BACKGROUND Venovenous extracorporeal membrane oxygenation (VV ECMO) can support trauma patients with severe respiratory failure. Use in traumatic brain injury (TBI) may raise concerns of worsening complications from intracranial bleeding. However, VV ECMO can rapidly correct hypoxemia and hypercarbia, possibly preventing secondary brain injury. We hypothesize that adult trauma patients with TBI on VV ECMO have comparable survival with trauma patients without TBI. METHODS A single-center, retrospective cohort study involving review of electronic medical records of trauma admissions between July 1, 2014, and August 30, 2022, with discharge diagnosis of TBI who were placed on VV ECMO during their hospital course was performed. RESULTS Seventy-five trauma patients were treated with VV ECMO; 36 (48%) had TBI. Of those with TBI, 19 (53%) had a hemorrhagic component. Survival was similar between patients with and without a TBI (72% vs. 64%, p = 0.45). Traumatic brain injury survivors had a higher admission Glasgow Coma Scale (7 vs. 3, p < 0.001) than nonsurvivors. Evaluation of prognostic scoring systems on initial head computed tomography demonstrated that TBI VV ECMO survivors were more likely to have a Rotterdam score of 2 (62% vs. 20%, p = 0.03) and no survivors had a Marshall score of ≥4. Twenty-nine patients (81%) had a repeat head computed tomography on VV ECMO with one incidence of expanding hematoma and one new focus of bleeding. Neither patient with a new/worsening bleed received anticoagulation. Survivors demonstrated favorable neurologic outcomes at discharge and outpatient follow-up, based on their mean Rancho Los Amigos Scale (6.5; SD, 1.2), median Cerebral Performance Category (2; interquartile range, 1-2), and median Glasgow Outcome Scale-Extended (7.5; interquartile range, 7-8). CONCLUSION In this series, the majority of TBI patients survived and had good neurologic outcomes despite a low admission Glasgow Coma Scale. Venovenous extracorporeal membrane oxygenation may minimize secondary brain injury and may be considered in select patients with TBI. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Samuel E Austin
- From the Program in Trauma (S.E.A., W.A.T., R.K., D.J.H., D.M.S., T.M.S., E.K.P.), R Adams Cowley Shock Trauma Center, Department of Surgery (S.E.A., R.K., D.J.H., D.M.S., T.M.S.), Department of Anesthesiology (S.M.G.), Neurocritical Care (J.E.P.), Program in Trauma, Department of Neurology, Department of Emergency Medicine (W.A.T., D.J.H., E.K.P.), and Department of Surgery (B.S.T.), Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and Department of Trauma and Acute Care Surgery (R.B.), University of Alabama at Birmingham, Birmingham, Alabama
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Radding S, Harfouche MN, Dhillon NK, Ko A, Hawley KL, Kundi R, Maddox JS, Radowsky JS, DuBose JJ, Feliciano DV, Kozar RA, Scalea TM. A pseudo-dilemma: Are we over-diagnosing and over-treating traumatic splenic intraparenchymal pseudoaneurysms? J Trauma Acute Care Surg 2024; 96:313-318. [PMID: 37599423 DOI: 10.1097/ta.0000000000004117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND Splenic embolization for traumatic vascular abnormalities in stable patients is a common practice. We hypothesize that modern contrast-enhanced computed tomography (CT) over diagnoses posttraumatic splenic vascular lesions, such as intraparenchymal pseudoaneurysms (PSA) that may not require embolization. METHODS We reviewed the experience at our high-volume center with endovascular management of blunt splenic injuries from January 2016 to December 2021. Multidisciplinary review was used to compared initial CT findings with subsequent angiography, analyzing management and outcomes of identified vascular lesions. RESULTS Of 853 splenic injuries managed overall during the study period, 255 (29.9%) underwent angiography of the spleen at any point during hospitalization. Vascular lesions were identified on 58% of initial CTs; extravasation (12.2%) and PSA (51.0%). Angiography was performed a mean of 22 hours after admission, with 38% done within 6 hours. Embolization was performed for 90.5% (231) of patients. Among the 130 patients with PSA on initial CT, 36 (27.7%) had no visible lesion on subsequent angiogram. From the 125 individuals who did not have a PSA identified on their initial CT, 67 (54%) had a PSA seen on subsequent angiography. On postembolization CT at 48 hours to 72 hours, persistently perfused splenic PSAs were seen in 41.0% (48/117) of those with and 22.2% (2/9) without embolization. Only one of 24 (4.1%) patients with PSA on angiography observed without embolization required delayed splenectomy, whereas 6.9% (16/231) in the embolized group had splenectomy at a mean of 5.5 ± 4 days after admission. CONCLUSION There is a high rate of discordance between CT and angiographic identification of splenic PSAs. Even when identified at angiogram and embolized, close to half will remain perfused on follow-up imaging. These findings question the use of routine angioembolization for all splenic PSAs. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Sydney Radding
- From the Department of Surgery (S.R.), Virginia Commonwealth University, Richmond, VA; R Adams Cowley Shock Trauma Center (M.N.H., N.K.D., K.L.H., R.K., J.S.M., J.S.R., D.V.F., R.A.K., T.M.S.), University of Maryland Medical System, Baltimore, Maryland; Department of Surgery (A.K.), Stanford University, Stanford, California; and Department of Surgery (J.J.DB.), University of Texas at Austin, Austin, Texas
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Kelley W, Zreik K, Gergen A, Williams J, Jacobson LE, Nahmias J, Tatar A, Murry J, Grigorian A, Ong A, Stein DM, Scalea TM, Lauerman MH. Early Pharmacologic Therapy in Patients With Blunt Cerebrovascular Injury and TBI: Is it Safe and Effective? An EAST Multicenter Study. Am Surg 2024:31348241230094. [PMID: 38253324 DOI: 10.1177/00031348241230094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) with concurrent traumatic brain injury (TBI) presents increased risk of both ischemic stroke and bleeding. This study investigated the safety and survival benefit of BCVI treatment (antithrombotic and/or anticoagulant therapy) in this population. We hypothesized that treatment would be associated with fewer and later strokes in patients with BCVI and TBI without increasing bleeding complications. METHODS Patients with head AIS >0 were selected from a database of BCVI patients previously obtained for an observational trial. A Kaplan-Meier analysis compared stroke survival in patients who received BCVI treatment to those who did not. Logistic regression was used to evaluate for confounding variables. RESULTS Of 488 patients, 347 (71.1%) received BCVI treatment and 141 (28.9%) did not. BCVI treatment was given at a median of 31 h post-admission. BCVI treatment was associated with lower stroke rate (4.9% vs 24.1%, P < .001 and longer stroke-free survival (P < .001), but also less severe systemic injury. Logistic regression identified motor GCS and BCVI treatment as the only predictors of stroke. No patients experienced worsening TBI because of treatment. DISCUSSION Patients with BCVI and TBI who did not receive BCVI treatment had an increased rate of stroke early in their hospital stay, though this effect may be confounded by worse motor deficits and systemic injuries. BCVI treatment within 2-3 days of admission may be safe for patients with mean head AIS of 2.6. Future prospective trials are needed to confirm these findings and determine optimal timing of BCVI treatment in TBI patients with BCVI.
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Affiliation(s)
- William Kelley
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Khaled Zreik
- Department of Surgery, Sanford Health, Sioux Falls, SD, USA
| | - Anna Gergen
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Jamie Williams
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, USA
| | - Lewis E Jacobson
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, USA
| | - Jeffry Nahmias
- Department of Surgery, University of California - Irvine, Irvine, CA, USA
| | - Anthony Tatar
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jason Murry
- Department of Surgery, UT Health Tyler, Tyler, TX, USA
| | - Areg Grigorian
- Department of Surgery, University of California - Irvine, Irvine, CA, USA
| | - Adrian Ong
- Department of Surgery, Towerhealth, West Reading, PA, USA
| | - Deborah M Stein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas M Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Margaret H Lauerman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Dhillon NK, Harfouche MN, Hawley KL, DuBose JJ, Kozar RA, Scalea TM. Embolization of Pseudoaneurysms is Associated With Improved Outcomes in Blunt Splenic Trauma. J Surg Res 2024; 293:656-662. [PMID: 37839096 DOI: 10.1016/j.jss.2023.08.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/27/2023] [Accepted: 08/27/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The necessity of angioembolization for all splenic pseudoaneurysms (PSAs) is unknown after blunt trauma. We compared the outcomes of patients with PSAs managed with splenic artery embolization (EMBO) versus no embolization (NO-EMBO). METHODS We retrospectively reviewed all patients with blunt splenic trauma and PSA on initial computed tomography scan admitted to an academic, urban, Level I trauma center from 2016 to 2021. Patients who had emergent splenectomy or died before discharge were excluded. Demographics, injury and computed tomography characteristics, and details regarding angiography, if pursued, were collected. The primary outcome was failure of nonoperative management (FNOM), as defined by need for delayed splenectomy for the EMBO group versus delayed splenectomy or embolization for the NO-EMBO group. RESULTS One hundred and fifty-six patients were in the final study population, of which 96 (61.5%) were in the EMBO group and 60 (38.5%) were in the NO-EMBO group. Patient demographics and mechanism of injury were similar between the two cohorts. The two cohorts had similar imaging findings, however, EMBO patients had more compartments with hemoperitoneum (2 versus 1, P < 0.01). Patients who underwent embolization had a lower FNOM rate (3.1% versus 13.3%, P = 0.02). CONCLUSIONS Splenic artery embolization in the setting of PSA is associated with lower rates of FNOM versus nonembolization. It is unclear if addressing the PSA itself with embolization drives the decreased FNOM rate.
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Affiliation(s)
- Navpreet K Dhillon
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Melike N Harfouche
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Kristy L Hawley
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Joseph J DuBose
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, Texas
| | - Rosemary A Kozar
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Thomas M Scalea
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland.
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Koh EY, Fox EE, Wade CE, Scalea TM, Fox CJ, Moore EE, Morse BC, Inaba K, Bulger EM, Meyer DE. Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy are associated with similar outcomes in traumatic cardiac arrest. J Trauma Acute Care Surg 2023; 95:912-917. [PMID: 37381147 PMCID: PMC10755074 DOI: 10.1097/ta.0000000000004094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive alternative to resuscitative thoracotomy (RT) for patients with hemorrhagic shock. However, the potential benefits of this approach remain subject of debate. The aim of this study was to compare the outcomes of REBOA and RT for traumatic cardiac arrest. METHODS A planned secondary analysis of the United States Department of Defense-funded Emergent Truncal Hemorrhage Control study was performed. Between 2017 and 2018, a prospective observational study of noncompressible torso hemorrhage was conducted at six Level I trauma centers. Patients were dichotomized by REBOA or RT, and baseline characteristics and outcomes were compared between groups. RESULTS A total of 454 patients were enrolled in the primary study, of which 72 patients were included in the secondary analysis (26 underwent REBOA and 46 underwent resuscitative thoracotomy). Resuscitative endovascular balloon occlusion of the aorta patients were older, had a greater body mass index, and were less likely to be the victims of penetrating trauma. Resuscitative endovascular balloon occlusion of the aorta patients also had less severe abdominal injuries and more severe extremity injuries, although the overall injury severity scores were similar. There was no difference in mortality between groups (88% vs. 93%, p = 0.767). However, time to aortic occlusion was longer in REBOA patients (7 vs. 4 minutes, p = 0.001) and they required more transfusions of red blood cells (4.5 vs. 2.5 units, p = 0.007) and plasma (3 vs. 1 unit, p = 0.032) in the emergency department. After adjusted analysis, mortality remained similar between groups (RR, 0.89; 95% confidence interval, 0.71-1.12, p = 0.304). CONCLUSION Resuscitative endovascular balloon occlusion of the aorta and RT were associated with similar survival after traumatic cardiac arrest, although time to successful aortic occlusion was longer in the REBOA group. Further research is needed to better define the role of REBOA in trauma. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Ezra Y. Koh
- Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Erin E. Fox
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX
| | - Charles E. Wade
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX
| | - Thomas M. Scalea
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD
| | - Charles J. Fox
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | | | - Kenji Inaba
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA
| | | | - David E. Meyer
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX
- Department of Surgery, University of Texas Health Science Center McGovern Medical School, Houston, TX
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Chung CY, Scalea TM. Damage control surgery: old concepts and new indications. Curr Opin Crit Care 2023; 29:666-673. [PMID: 37861194 DOI: 10.1097/mcc.0000000000001097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW While the principles of damage control surgery - rapid hemorrhage and contamination control with correction of physiologic derangements followed by delayed definitive reconstruction - have remained consistent, forms of damage control intervention have evolved and proliferated dramatically. This review aims to provide a historic perspective of the early trends of damage control surgery as well as an updated understanding of its current state and future trends. RECENT FINDINGS Physiologically depleted patients in shock due to both traumatic and nontraumatic causes are often treated with damage control laparotomy and surgical principles. Damage control surgery has also been shown to be safe and effective in thoracic and orthopedic injuries. Damage control resuscitation is used in conjunction with surgical source control to restore patient physiology and prevent further collapse. The overuse of damage control laparotomy, however, is associated with increased morbidity and complications. With advancing technology, catheter- and stent-based endovascular modalities are playing a larger role in the resuscitation and definitive care of patients. SUMMARY Optimal outcome in the care of the most severely injured patients requires judicious use of damage control surgery supplemented by advancements in resuscitation and surgical adjuncts.
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Affiliation(s)
- C Yvonne Chung
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
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Walker PF, Galvagno SM, Sachdeva A, Feliciano DV, Scalea TM, O'Connor JV. Operative Management of Aerodigestive Injuries: Improved Survival Over two Decades. Am Surg 2023; 89:5982-5987. [PMID: 37283249 DOI: 10.1177/00031348231180917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Non-iatrogenic aerodigestive injuries are infrequent but potentially fatal. We hypothesize that advances in management and adoption of innovative therapies resulted in improved survival. METHODS Trauma registry review at a university Level 1 center from 2000 to 2020 that identified adults with aerodigestive injuries requiring operative or endoluminal intervention. Demographics, injuries, operations, and outcomes were abstracted. Univariate analysis was performed, P < .05 was statistically significant. RESULTS 95 patients had 105 injuries: 68 tracheal and 37 esophageal (including 10 combined). Mean age 30.9 (± 14), 87.4% male, 82.1% penetrating, and 28.4% with vascular injuries. Median ISS, chest AIS, admission BP, Shock Index, and lactate were 26 (16-34), 4 (3-4), 132 (113-149) mmHg, .8 (.7-1.1), and 3.1 (2.4-5.6) mmol/L, respectively. There were 46 cervical and 22 thoracic airway injuries; 5 patients in extremis required preoperative ECMO. 66 airway injuries were surgically repaired and 2 definitively managed with endobronchial stents. There were 24 cervical, 11 thoracic, 2 abdominal esophageal injuries-all repaired surgically. Combined tracheoesophageal injuries were individually managed and buttressed. 4 airway complications were successfully managed, and 11 esophageal complications managed conservatively, stented, or resected. Mortality was 9.6%, half from intraoperative hemorrhage. Specific mortality: tracheobronchial 8.8%, esophageal 10.8%, and combined 20%. Mortality was significantly associated with higher ISS (P = .01), vascular injury (P = .007), blunt mechanism (P = .01), bronchial injury (P = .01), and years 2000-2010 (P = .03), but not combined tracheobronchial injury. CONCLUSION Mortality is associated with several variables, including vascular trauma and years 2000-2010. The use of ECMO and endoluminal stents in highly selected patients and institutional experience may account for 97.8% survival over the past decade.
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Affiliation(s)
| | - Samuel M Galvagno
- RA Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | | | - David V Feliciano
- RA Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Thomas M Scalea
- RA Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - James V O'Connor
- RA Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
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15
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Ardeshna S, Esposito E, Spalding C, Dunn J, Nahmias J, Grigorian A, Harmon L, Gergen A, Young A, Pascual J, Murry J, Ong A, Appelbaum R, Bugaev N, Tatar A, Zreik K, Scalea TM, Stein D, Lauerman M. Which Patients Receive Diagnostic Angiography? An EAST Multicenter Study Analysis of Internal Carotid Artery Blunt Cerebrovascular Injury. Am Surg 2023; 89:5183-5190. [PMID: 36417771 DOI: 10.1177/00031348221138083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Digital subtraction angiography (DSA) is the gold standard radiologic modality in blunt cerebrovascular injury (BCVI). However, computerized tomography angiography (CTA) is primarily used in modern practice with CTA's widespread availability and the decreased stroke rate with CTA use. The frequency and indications for DSA in BCVI is undefined. We hypothesized that DSA use in internal carotid artery (ICA) BCVI would be infrequent and dependent on radiologic features. METHODS This was a post hoc analysis of an EAST multicenter, prospective, observational trial of 16 trauma centers for stroke factors in BCVI. ICA BCVI was divided into those undergoing DSA and not undergoing DSA (no-DSA). Only ICA BCVI was included. RESULTS 332 ICA BCVI were included, 221 (66.6%) no-DSA and 111 (33.4%) DSA. Lower hospital trauma volume, non-urban environment, and non-academic status were associated with DSA use (all P ≤ .001). BCVI grade (P = .02) and presence of luminal stenosis (P = .005) were associated with DSA use while pseudoaneurysm presence was not. Median time to DSA was 1 hour. The most common indication for angiography was to determine the presence of injury in 71 (64%) ICA BCVI, followed by determining grade of injury in 16 (14.4%) and concerning imaging characteristics in 12 (10.8%). BCVI grade on initial imaging and on DSA were equivalent in 94 (84.7%) ICA BCVI. DISCUSSION DSA is frequently used in ICA BCVI, primarily early in the hospital course for injury diagnosis and grade determination. DSA appears primarily driven by hospital type, BCVI grade, and luminal stenosis.
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Affiliation(s)
| | | | | | - Julie Dunn
- University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | | | | | | | - Anna Gergen
- University of Colorado Denver, Denver, CO, USA
| | - Andrew Young
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jose Pascual
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | - Rachel Appelbaum
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Antony Tatar
- Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Deborah Stein
- R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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16
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Frassini S, Cobianchi L, Fugazzola P, Biffl WL, Coccolini F, Damaskos D, Moore EE, Kluger Y, Ceresoli M, Coimbra R, Davies J, Kirkpatrick A, Di Carlo I, Hardcastle TC, Isik A, Chiarugi M, Gurusamy K, Maier RV, Segovia Lohse HA, Jeekel H, Boermeester MA, Abu-Zidan F, Inaba K, Weber DG, Augustin G, Bonavina L, Velmahos G, Sartelli M, Di Saverio S, Ten Broek RPG, Granieri S, Dal Mas F, Farè CN, Peverada J, Zanghì S, Viganò J, Tomasoni M, Dominioni T, Cicuttin E, Hecker A, Tebala GD, Galante JM, Wani I, Khokha V, Sugrue M, Scalea TM, Tan E, Malangoni MA, Pararas N, Podda M, De Simone B, Ivatury R, Cui Y, Kashuk J, Peitzman A, Kim F, Pikoulis E, Sganga G, Chiara O, Kelly MD, Marzi I, Picetti E, Agnoletti V, De'Angelis N, Campanelli G, de Moya M, Litvin A, Martínez-Pérez A, Sall I, Rizoli S, Tomadze G, Sakakushev B, Stahel PF, Civil I, Shelat V, Costa D, Chichom-Mefire A, Latifi R, Chirica M, Amico F, Pardhan A, Seenarain V, Boyapati N, Hatz B, Ackermann T, Abeyasundara S, Fenton L, Plani F, Sarvepalli R, Rouhbakhshfar O, Caleo P, Ho-Ching Yau V, Clement K, Christou E, Castillo AMG, Gosal PKS, Balasubramaniam S, Hsu J, Banphawatanarak K, Pisano M, Toro A, Michele A, Cioffi SPB, Spota A, Catena F, Ansaloni L. Correction: ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings. World J Emerg Surg 2023; 18:52. [PMID: 38012756 PMCID: PMC10683098 DOI: 10.1186/s13017-023-00522-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Simone Frassini
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy.
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy.
| | - Lorenzo Cobianchi
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Paola Fugazzola
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Walter L Biffl
- Department of Emergency and Trauma Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Dimitrios Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Claremont, CA, USA
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Andrew Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Canada
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Unit, Cannizzaro Hospital, Catania, Italy
| | - Timothy C Hardcastle
- Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, 4001, South Africa
- Trauma and Burns Services, Inkosi Albert Luthuli Central Hospital, Mayville, 4058, South Africa
| | - Arda Isik
- Division of General Surgery, School of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, London, UK
| | - Ronald V Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Helmut A Segovia Lohse
- II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Hans Jeekel
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, 1105AZ, Amsterdam, The Netherlands
| | - Fikri Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE
| | - Kenji Inaba
- Los Angeles County + USC Medical Center, 2051 Marengo Street, Room C5L100, Los Angeles, CA, 90033, USA
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Luigi Bonavina
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Salomone Di Saverio
- Unit of General Surgery, San Benedetto del Tronto Hospital, av5 Asur Marche, San Benedetto del Tronto, Italy
| | | | - Stefano Granieri
- General Surgery Unit, ASST Vimercate, Via Santi Cosma E Damiano, 10, 20871, Vimercate, Italy
| | - Francesca Dal Mas
- Department of Management, Università Ca' Foscari, Dorsoduro 3246, 30123, Venezia, Italy
| | - Camilla Nikita Farè
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Jacopo Peverada
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Simone Zanghì
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Jacopo Viganò
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Matteo Tomasoni
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Tommaso Dominioni
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Enrico Cicuttin
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Giovanni D Tebala
- Department of Digestive and Emergency Surgery, S. Maria Hospital Trust, Terni, Italy
| | - Joseph M Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | | | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Michael Sugrue
- Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Thomas M Scalea
- Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD, USA
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark A Malangoni
- Department of Surgery, MetroHealth Medical Center Campus, Case Western Reserve University, Cleveland, OH, 44109, USA
| | - Nikolaos Pararas
- Third Department of Surgery, Attikon University Hospital, 15772, Athens, Greece
| | - Mauro Podda
- Department of Surgical Science, Cagliari State University, Cagliari, Italy
| | - Belinda De Simone
- Department of Emergency Surgery, Centre Hospitalier Intercommunal de Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA, USA
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Jeffry Kashuk
- Department of Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andrew Peitzman
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Fernando Kim
- Denver Health Medical Center, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Emmanouil Pikoulis
- Medical School, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A.Gemelli IRCCS, Università Cattolica, Rome, Italy
| | - Osvaldo Chiara
- Trauma Center and Emergency Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Michael D Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, Ospedale M Bufalini, Cesena, Italy
| | - Nicola De'Angelis
- Service de Chirurgie Digestive et Hépato-Bilio-Pancréatique, Hôpital Henri Mondor, Université Paris Est, Créteil, France
| | - Giampiero Campanelli
- Division of General Surgery, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Insubria, Varese, Italy
| | - Marc de Moya
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrey Litvin
- AI Medica Hospital Center / Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Aleix Martínez-Pérez
- Faculty of Health Sciences, Valencian International University (VIU), Valencia, Spain
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal
| | | | - Gia Tomadze
- Department of Surgery, Tbilisi State Medical University, Tbilisi, Georgia
| | | | - Philip F Stahel
- Department of Orthopedic Surgery and Neurosurgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Ian Civil
- Trauma Service, Auckland City Hospital, Auckland, New Zealand
| | | | - David Costa
- Department of General y Digestive Surgery, "Dr. Balmis" Alicante General University Hospital, Alicante, Spain
| | | | - Rifat Latifi
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Mircea Chirica
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Francesco Amico
- Department of Traumatology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Vidya Seenarain
- Acute Surgical Unit, Department of General Surgery, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Nikitha Boyapati
- Acute Surgical Unit, Department of General Surgery, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Basil Hatz
- State Major Trauma Unit, Royal Perth Hospital, Wellington Street, Perth, Australia
| | - Travis Ackermann
- General Surgery, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia
| | - Sandun Abeyasundara
- Department of Colorectal Surgery, Logan Hospital, Meadowbrook, QLD, Australia
| | - Linda Fenton
- Maitland Private Hospital, East Maitland, Newcastle, NSW, Australia
| | - Frank Plani
- Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Rohit Sarvepalli
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Omid Rouhbakhshfar
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Pamela Caleo
- Nambour Selangor Private Hospital, Sunshine Coast University Private Hospital, Birtinya, QLD, Australia
| | | | - Kristenne Clement
- Department of Surgery, Nepean Hospital, Penrith, NSW, 2751, Australia
| | - Erasmia Christou
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | | | - Preet K S Gosal
- Department of General Surgery, Nepean Hospital, Sydney, NSW, Australia
| | - Sunder Balasubramaniam
- Department of Trauma, Westmead Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Jeremy Hsu
- Department of Trauma, Westmead Hospital, The University of Sydney, Sydney, NSW, Australia
| | | | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Adriana Toro
- General Surgery, Augusta Hospital, Augusta, Italy
| | - Altomare Michele
- Trauma Center and Emergency Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano P B Cioffi
- Trauma Center and Emergency Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Spota
- Trauma Center and Emergency Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fausto Catena
- Acute Care Surgery Unit, Department of Surgery and Trauma, Maurizio Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
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17
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Treffalls RN, Scheidt J, Lee C, Laverty RB, DuBose JJ, Scalea TM, Moore LJ, Podbielski JM, Inaba K, Piccinini A, Kauvar DS. Arterial Access Complications Following Percutaneous Femoral Access in 24-Hour Resuscitative Endovascular Balloon Occlusion of the Aorta Survivors. J Surg Res 2023; 290:203-208. [PMID: 37271068 DOI: 10.1016/j.jss.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/06/2023]
Abstract
INTRODUCTION With the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) comes the potential for vascular access site complications (VASCs) and limb ischemic sequelae. We aimed to determine the prevalence of VASC and associated clinical and technical factors. METHODS A retrospective cohort analysis of 24-h survivors undergoing percutaneous REBOA via the femoral artery in the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute care surgery registry between Oct 2013 and Sep 2021 was performed. The primary outcome was VASC, defined as at least one of the following: hematoma, pseudoaneurysm, arteriovenous fistula, arterial stenosis, or the use of patch angioplasty for arterial closure. Associated clinical and procedural variables were examined. Data were analyzed using Fisher exact test, Mann-Whitney-U tests, and linear regression. RESULTS There were 34 (7%) cases with VASC among 485 meeting inclusion criteria. Hematoma (40%) was the most common, followed by pseudoaneurysm (26%) and patch angioplasty (21%). No differences in demographics or injury/shock severity were noted between cases with and without VASC. The use of ultrasound (US) was protective (VASC, 35% versus no VASC, 51%; P = 0.05). The VASC rate in US cases was 12/242 (5%) versus 22/240 (9.2%) without US. Arterial sheath size >7 Fr was not associated with VASC. US use increased over time (R2 = 0.94, P < 0.001) with a stable rate of VASC (R2 = 0.78, P = 0.61). VASC were associated with limb ischemia (VASC, 15% versus no VASC, 4%; P = 0.006) and arterial bypass procedures (VASC 3% versus no VASC 0%; P < 0.001) but amputation was uncommon (VASC, 3% versus no VASC, 0.4%; P = 0.07). CONCLUSIONS Percutaneous femoral REBOA had a 7% VASC rate which was stable over time. VASC are associated with limb ischemia but need for surgical intervention and/or amputation is rare. The use of US-guided access appears to be protective against VASC and is recommended for use in all percutaneous femoral REBOA procedures.
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Affiliation(s)
| | - Justin Scheidt
- Department of Surgery, Brooke Army Medical Center, Texas
| | - Christina Lee
- Department of Surgery, Brooke Army Medical Center, Texas
| | | | | | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Laura J Moore
- University of Texas Health Sciences Center - Houston, Houston, Texas
| | | | - Kenji Inaba
- Los Angeles County + University of Southern California Hospital, Los Angeles, California
| | - Alice Piccinini
- Los Angeles County + University of Southern California Hospital, Los Angeles, California
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18
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Dave SB, Rabinowitz R, Shah A, Tabatabai A, Galvagno SM, Mazzeffi MA, Rector R, Kaczorowski DJ, Scalea TM, Menaker J. COVID-19 outcomes of venovenous extracorporeal membrane oxygenation for acute respiratory failure vs historical cohort of non-COVID-19 viral infections. Perfusion 2023; 38:1165-1173. [PMID: 35653427 PMCID: PMC9168413 DOI: 10.1177/02676591221105603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become a support modality for patients with acute respiratory failure refractory to standard therapies. VV ECMO has been increasingly used during the current COVID-19 pandemic for patients with refractory respiratory failure. The object of this study was to evaluate the outcomes of VV ECMO in patients with COVID-19 compared to patients with non-COVID-19 viral infections. METHODS We retrospectively reviewed all patients supported with VV ECMO between 8/2014 and 8/2020 whose etiology of illness was a viral pulmonary infection. The primary outcome of this study was to evaluate in-hospital mortality. The secondary outcomes included length of ECMO course, ventilator duration, hospital length of stay, incidence of adverse events through ECMO course. RESULTS Eighty-nine patients were included (35 COVID-19 vs 54 non-COVID-19). Forty (74%) of the non-COVID-19 patients had influenza virus. Prior to cannulation, COVID-19 patients had longer ventilator duration (3 vs 1 day, p = .003), higher PaCO2 (64 vs 53 mmHg, p = .012), and white blood cell count (14 vs 9 ×103/μL, p = .004). Overall in-hospital mortality was 33.7% (n = 30). COVID-19 patients had a higher mortality (49% vs. 24%, p = .017) when compared to non-COVID-19 patients. COVID-19 survivors had longer median time on ECMO than non-COVID-19 survivors (24.4 vs 16.5 days p = .03) but had a similar hospital length of stay (HLOS) (41 vs 48 Extracorporeal Membrane Oxygenationdays p = .33). CONCLUSION COVID-19 patients supported with VV ECMO have a higher mortality than non-COVID-19 patients. While COVID-19 survivors had significantly longer VV ECMO runs than non-COVID-19 survivors, HLOS was similar. This data add to a growing body of literature supporting the use of ECMO for potentially reversible causes of respiratory failure.
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Affiliation(s)
- Sagar B Dave
- Department of Emergency Medicine,
Department of Anesthesiology, Division of Critical Care,
Emory
University School of Medicine, Atlanta,
GA, USA
| | - Ronald Rabinowitz
- Department of Medicine, Program in
Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of
Medicine, Baltimore, MD, USA
| | - Aakash Shah
- Department of Surgery, Division of
Cardiac Surgery, University of Maryland School of
Medicine, Baltimore, MD, USA
| | - Ali Tabatabai
- Department of Medicine, Division of
Pulmonary and Critical Care, Program in Trauma, R Adams Cowley Shock Trauma
Center, University
of Maryland School of Medicine,
Baltimore, MD, USA
| | - Samuel M Galvagno
- Department of Anesthesiology,
Program in Trauma, R Adams Cowley Shock Trauma Center,
University
of Maryland School of Medicine,
Baltimore, MD, USA
| | - Michael A Mazzeffi
- Department of Anesthesiology and
Critical Care Medicine, George Washington School of Medicine and
Health Sciences, Washington, DC,
USA
| | - Raymond Rector
- Perfusion Services,
University
of Maryland Medical Center, Baltimore,
MD, USA
| | - David J Kaczorowski
- Department of Cardiothoracic
Surgery, University
of Pittsburgh Medical Center,
Pittsburgh, PA, USA
| | - Thomas M Scalea
- Department of Surgery, Program in
Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of
Medicine, Baltimore, MD, USA
| | - Jay Menaker
- Department of Surgery, Johns
Hopkins Medicine, Howard County General
Hospital, Columbia, MD, USA
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19
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Frassini S, Cobianchi L, Fugazzola P, Biffl WL, Coccolini F, Damaskos D, Moore EE, Kluger Y, Ceresoli M, Coimbra R, Davies J, Kirkpatrick A, Di Carlo I, Hardcastle TC, Isik A, Chiarugi M, Gurusamy K, Maier RV, Segovia Lohse HA, Jeekel H, Boermeester MA, Abu-Zidan F, Inaba K, Weber DG, Augustin G, Bonavina L, Velmahos G, Sartelli M, Di Saverio S, Ten Broek RPG, Granieri S, Dal Mas F, Farè CN, Peverada J, Zanghì S, Viganò J, Tomasoni M, Dominioni T, Cicuttin E, Hecker A, Tebala GD, Galante JM, Wani I, Khokha V, Sugrue M, Scalea TM, Tan E, Malangoni MA, Pararas N, Podda M, De Simone B, Ivatury R, Cui Y, Kashuk J, Peitzman A, Kim F, Pikoulis E, Sganga G, Chiara O, Kelly MD, Marzi I, Picetti E, Agnoletti V, De'Angelis N, Campanelli G, de Moya M, Litvin A, Martínez-Pérez A, Sall I, Rizoli S, Tomadze G, Sakakushev B, Stahel PF, Civil I, Shelat V, Costa D, Chichom-Mefire A, Latifi R, Chirica M, Amico F, Pardhan A, Seenarain V, Boyapati N, Hatz B, Ackermann T, Abeyasundara S, Fenton L, Plani F, Sarvepalli R, Rouhbakhshfar O, Caleo P, Ho-Ching Yau V, Clement K, Christou E, Castillo AMG, Gosal PKS, Balasubramaniam S, Hsu J, Banphawatanarak K, Pisano M, Adriana T, Michele A, Cioffi SPB, Spota A, Catena F, Ansaloni L. ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings. World J Emerg Surg 2023; 18:42. [PMID: 37496068 PMCID: PMC10373269 DOI: 10.1186/s13017-023-00511-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/18/2023] [Indexed: 07/28/2023] Open
Abstract
Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy.
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Affiliation(s)
- Simone Frassini
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy.
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy.
| | - Lorenzo Cobianchi
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Paola Fugazzola
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Walter L Biffl
- Department of Emergency and Trauma Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Dimitrios Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Claremont, CA, USA
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Andrew Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Canada
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Unit, Cannizzaro Hospital, Catania, Italy
| | - Timothy C Hardcastle
- Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, 4001, South Africa
- Trauma and Burns Services, Inkosi Albert Luthuli Central Hospital, Mayville, 4058, South Africa
| | - Arda Isik
- Division of General Surgery, School of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, London, UK
| | - Ronald V Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Helmut A Segovia Lohse
- II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Hans Jeekel
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, 1105AZ, Amsterdam, The Netherlands
| | - Fikri Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE
| | - Kenji Inaba
- Los Angeles County + USC Medical Center, 2051 Marengo Street, Room C5L100, Los Angeles, CA, 90033, USA
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Luigi Bonavina
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Salomone Di Saverio
- Unit of General Surgery, San Benedetto del Tronto Hospital, av5 Asur Marche, San Benedetto del Tronto, Italy
| | | | - Stefano Granieri
- General Surgery Unit, ASST Vimercate, Via Santi Cosma E Damiano, 10, 20871, Vimercate, Italy
| | - Francesca Dal Mas
- Department of Management, Università Ca' Foscari, Dorsoduro 3246, 30123, Venezia, Italy
| | - Camilla Nikita Farè
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Jacopo Peverada
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Simone Zanghì
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Jacopo Viganò
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Matteo Tomasoni
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Tommaso Dominioni
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Enrico Cicuttin
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Giovanni D Tebala
- Department of Digestive and Emergency Surgery, S. Maria Hospital Trust, Terni, Italy
| | - Joseph M Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | | | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Michael Sugrue
- Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Thomas M Scalea
- Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD, USA
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark A Malangoni
- Department of Surgery, MetroHealth Medical Center Campus, Case Western Reserve University, Cleveland, OH, 44109, USA
| | - Nikolaos Pararas
- Third Department of Surgery, Attikon University Hospital, 15772, Athens, Greece
| | - Mauro Podda
- Department of Surgical Science, Cagliari State University, Cagliari, Italy
| | - Belinda De Simone
- Department of Emergency Surgery, Centre Hospitalier Intercommunal de Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA, USA
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Jeffry Kashuk
- Department of Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andrew Peitzman
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Fernando Kim
- Denver Health Medical Center, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Emmanouil Pikoulis
- Medical School, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A.Gemelli IRCCS, Università Cattolica, Rome, Italy
| | - Osvaldo Chiara
- Trauma Center and Emergency Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Michael D Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, Ospedale M Bufalini, Cesena, Italy
| | - Nicola De'Angelis
- Service de Chirurgie Digestive et Hépato-Bilio-Pancréatique, Hôpital Henri Mondor, Université Paris Est, Créteil, France
| | - Giampiero Campanelli
- Division of General Surgery, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Insubria, Varese, Italy
| | - Marc de Moya
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrey Litvin
- AI Medica Hospital Center / Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Aleix Martínez-Pérez
- Faculty of Health Sciences, Valencian International University (VIU), Valencia, Spain
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal
| | | | - Gia Tomadze
- Department of Surgery, Tbilisi State Medical University, Tbilisi, Georgia
| | | | - Philip F Stahel
- Department of Orthopedic Surgery and Neurosurgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Ian Civil
- Trauma Service, Auckland City Hospital, Auckland, New Zealand
| | | | - David Costa
- Department of General y Digestive Surgery, "Dr. Balmis" Alicante General University Hospital, Alicante, Spain
| | | | - Rifat Latifi
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Mircea Chirica
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Francesco Amico
- Department of Traumatology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Vidya Seenarain
- Acute Surgical Unit, Department of General Surgery, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Nikitha Boyapati
- Acute Surgical Unit, Department of General Surgery, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Basil Hatz
- State Major Trauma Unit, Royal Perth Hospital, Wellington Street, Perth, Australia
| | - Travis Ackermann
- General Surgery, Monash Medical Centre, Monash Health, Melbourne, VIC, Australia
| | - Sandun Abeyasundara
- Department of Colorectal Surgery, Logan Hospital, Meadowbrook, QLD, Australia
| | - Linda Fenton
- Maitland Private Hospital, East Maitland, Newcastle, NSW, Australia
| | - Frank Plani
- Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Rohit Sarvepalli
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Omid Rouhbakhshfar
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Pamela Caleo
- Nambour Selangor Private Hospital, Sunshine Coast University Private Hospital, Birtinya, QLD, Australia
| | | | - Kristenne Clement
- Department of Surgery, Nepean Hospital, Penrith, NSW, 2751, Australia
| | - Erasmia Christou
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | | | - Preet K S Gosal
- Department of General Surgery, Nepean Hospital, Sydney, NSW, Australia
| | - Sunder Balasubramaniam
- Department of Trauma, Westmead Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Jeremy Hsu
- Department of Trauma, Westmead Hospital, The University of Sydney, Sydney, NSW, Australia
| | | | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Toro Adriana
- General Surgery, Augusta Hospital, Augusta, Italy
| | - Altomare Michele
- Trauma Center and Emergency Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano P B Cioffi
- Trauma Center and Emergency Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Spota
- Trauma Center and Emergency Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fausto Catena
- Acute Care Surgery Unit, Department of Surgery and Trauma, Maurizio Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- University of Pavia, Corso Str. Nuova, 65, 27100, Pavia, Italy
- Unit of General Surgery I, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100, Pavia, Italy
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20
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Yang S, Esposito E, Spalding C, Simpson J, Dunn JA, Zier L, Burruss S, Kim P, Jacobson LE, Williams J, Nahmias J, Grigorian A, Harmon L, Gergen A, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Appelbaum R, Bugaev N, Tatar A, Zreik K, Lieser MJ, Scalea TM, Stein DM, Lauerman M. Grade 1 Internal Carotid Artery Blunt Cerebrovascular Injury Persistence Risks Stroke With Current Management: An EAST Multicenter Study. Am Surg 2023; 89:2618-2627. [PMID: 35652129 DOI: 10.1177/00031348221082277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Higher blunt cerebrovascular injury (BCVI) grade and lack of medical therapy are associated with stroke. Knowledge of stroke risk factors specific to individual grades may help tailor BCVI therapy to specific injury characteristics. METHODS A post-hoc analysis of a 16 center, prospective, observational trial (2018-2020) was performed including grade 1 internal carotid artery (ICA) BCVI. Repeat imaging was considered the second imaging occurrence only. RESULTS From 145 grade 1 ICA BCVI included, 8 (5.5%) suffered a stroke. Grade 1 ICA BCVI with stroke were more commonly treated with mixed anticoagulation and antiplatelet therapy (75.0% vs 9.6%, P <.001) and less commonly antiplatelet therapy (25.0% vs 82.5%, P = .001) compared to injuries without stroke. Of the 8 grade 1 ICA BCVI with stroke, 4 (50.0%) had stroke after medical therapy was started. In comparing injuries with resolution at repeat imaging to those without, stroke occurred in 7 (15.9%) injuries without resolution and 0 (0%) injuries with resolution (P = .005). At repeat imaging in grade 1 ICA BCVI with stroke, grade of injury was grade 1 in 2 injuries, grade 2 in 3 injuries, grade 3 in 1 injury, and grade 5 in one injury. DISCUSSION While the stroke rate for grade 1 ICA BCVI is low overall, injury persistence appears to heighten stroke risk. Some strokes occurred despite initiation of medical therapy. Repeat imaging is needed in grade 1 ICA BCVI to evaluate for injury progression or resolution.
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Affiliation(s)
- Sarah Yang
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Esposito
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | | - Linda Zier
- University of Colorado, Loveland, CO, USA
| | | | - Paul Kim
- Loma Linda University, Loma Linda, CA, USA
| | | | | | | | | | | | | | | | | | - Andrew J Young
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jose L Pascual
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | | | | | | - Antony Tatar
- Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah M Stein
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Margaret Lauerman
- R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
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21
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Kelly MA, Pinet-Peralta LM, Roque TM, Scalea TM, Delbridge TR, Galvagno SM. The Maryland (USA) Critical Care Coordination Center (C4): From Pandemic to Permanence. Prehosp Disaster Med 2023; 38:311-318. [PMID: 37313688 DOI: 10.1017/s1049023x23005782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION The 2019 coronavirus disease (COVID-19) pandemic created overwhelming demand for critical care services within Maryland's (USA) hospital systems. As intensive care units (ICUs) became full, critically ill patients were boarded in hospital emergency departments (EDs), a practice associated with increased mortality and costs. Allocation of critical care resources during the pandemic requires thoughtful and proactive management strategies. While various methodologies exist for addressing the issue of ED overcrowding, few systems have implemented a state-wide response using a public safety-based platform. The objective of this report is to describe the implementation of a state-wide Emergency Medical Services (EMS)-based coordination center designed to ensure timely and equitable access to critical care. METHODS The state of Maryland designed and implemented a novel, state-wide Critical Care Coordination Center (C4) staffed with intensivist physicians and paramedics purposed to ensure appropriate critical care resource management and patient transfer assistance. A narrative description of the C4 is provided. A retrospective cohort study design was used to present requests to the C4 as a case series report to describe the results of implementation. RESULTS Providing a centralized asset with regional situational awareness of hospital capability and bed status played an integral role for directing the triage process of critically ill patients to appropriate facilities during and after the COVID-19 pandemic. A total of 2,790 requests were received by the C4. The pairing of a paramedic with an intensivist physician resulted in the successful transfer of 67.4% of requests, while 27.8% were managed in place with medical direction. Overall, COVID-19 patients comprised 29.5% of the cohort. Data suggested increased C4 usage was predictive of state-wide ICU surges. The C4 usage volume resulted in the expansion to pediatric services to serve a broader age range. The C4 concept, which leverages the complimentary skills of EMS clinicians and intensivist physicians, is presented as a proposed public safety-based model for other regions to consider world-wide. CONCLUSION The C4 has played an integral role in the State of Maryland's pledge to its citizens to deliver the right care to the right patient at the right time and can be considered as a model for adoption by other regions world-wide.
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Affiliation(s)
- Melissa A Kelly
- Maryland Institute for Emergency Medical Services Systems (MIEMSS), Baltimore, MarylandUSA
| | - Luis M Pinet-Peralta
- Maryland Institute for Emergency Medical Services Systems (MIEMSS), Baltimore, MarylandUSA
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, MarylandUSA
| | - Tara M Roque
- Maryland Institute for Emergency Medical Services Systems (MIEMSS), Baltimore, MarylandUSA
- Suburban Hospital, Johns Hopkins Medicine, Department of Critical Care, Bethesda, MarylandUSA
| | - Thomas M Scalea
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MarylandUSA
| | - Theodore R Delbridge
- Maryland Institute for Emergency Medical Services Systems (MIEMSS), Baltimore, MarylandUSA
| | - Samuel M Galvagno
- Maryland Institute for Emergency Medical Services Systems (MIEMSS), Baltimore, MarylandUSA
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MarylandUSA
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22
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Harfouche MN, Feliciano DV, Kozar RA, DuBose JJ, Scalea TM. A Cautionary Tale: The Use of Propensity Matching to Evaluate Hemorrhage-Related Trauma Mortality in the American College of Surgeons TQIP Database. J Am Coll Surg 2023; 236:1208-1216. [PMID: 36847370 DOI: 10.1097/xcs.0000000000000669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Propensity-matched methods are increasingly being applied to the American College of Surgeons TQIP database to evaluate hemorrhage control interventions. We used variation in systolic blood pressure (SBP) to demonstrate flaws in this approach. STUDY DESIGN Patients were divided into groups based on initial SBP (iSBP) and SBP at 1 hour (2017 to 2019). Groups were defined as follows: iSBP 90 mmHg or less who decompensated to 60 mmHg or less (immediate decompensation [ID]), iSBP 90 mmHg or less who remained greater than 60 mmHg (stable hypotension [SH]), and iSBP greater than 90 mmHg who decompensated to 60 mmHg or less (delayed decompensation [DD]). Individuals with Head or Spine Abbreviated Injury Scale score 3 or greater were excluded. Propensity score was assigned using demographic and clinical variables. Outcomes of interest were in-hospital mortality, emergency department death, and overall length of stay. RESULTS Propensity matching yielded 4,640 patients per group in analysis #1 (SH vs DD) and 5,250 patients per group in analysis #2 (SH vs ID). The DD and ID groups had 2-fold higher in-hospital mortality than the SH group (DD 30% vs 15%, p < 0.001; ID 41% vs 18%, p < 0.001). Emergency department death rate was 3 times higher in the DD group and 5 times higher in the ID group (p < 0.001), and length of stay was 4 days shorter in the DD group and 1 day shorter in the ID group (p < 0.001). Odds of death were 2.6 times higher for the DD vs SH group and 3.2 times higher for the ID vs SH group (p < 0.001). CONCLUSIONS Differences in mortality rate by SBP variation underscore the difficulty of identifying individuals with a similar degree of hemorrhagic shock using the American College of Surgeons TQIP database despite propensity matching. Large databases lack the detailed data needed to rigorously evaluate hemorrhage control interventions.
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Affiliation(s)
- Melike N Harfouche
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - David V Feliciano
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - Rosemary A Kozar
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - Joseph J DuBose
- Dell Medical School, University of Texas at Austin, Austin, TX (DuBose)
| | - Thomas M Scalea
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
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23
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Powell MEK, Reynolds TS, Webb JK, Kundi R, Cantu J, Keville M, O'Connor JV, Stein DM, Hanson MP, Taylor BS, Scalea TM, Galvagno SM. Early Veno-venous Extracorporeal Membrane Oxygenation is an Effective Strategy for Traumatically Injured Patients Presenting with Refractory Respiratory Failure. J Trauma Acute Care Surg 2023:01586154-990000000-00388. [PMID: 37246288 PMCID: PMC10389478 DOI: 10.1097/ta.0000000000004057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Veno-venous extracorporeal membrane oxygenation (VV ECMO) is used for respiratory failure when standard therapy fails. Optimal trauma care requires patients be stable enough to undergo procedures. Early VV ECMO (EVV) to stabilize trauma patients with respiratory failure as part of resuscitation could facilitate additional care. As VV ECMO technology is portable and prehospital cannulation possible, it could also be used in austere environments. We hypothesize that EVV facilitates injury care without worsening survival. METHODS Our single center, retrospective cohort study included all trauma patients between January 1, 2014, and August 1, 2022, who were placed on VV ECMO. EVV was defined as cannulation ≤48 hours from arrival with subsequent operation for injuries. Data were analyzed with descriptive statistics. Parametric or nonparametric statistics were used based on the nature of the data. After testing for normality, significance was defined as a p < 0.05. Logistic regression diagnostics were performed. RESULTS Seventy-five patients were identified and 57 (76%) underwent EVV. There was no difference in survival between the EVV and non-EVV groups (70% v 61%, p = 0.47). Age, race, and gender did not differ between EVV survivors and non-survivors. Time to cannulation (4.5 h v 8 h, p = 0.39) and injury severity scores (34 v 29, p = 0.74) were similar. EVV survivors had lower lactic acid levels pre-cannulation (3.9 mmol/L v 11.9 mmol/L, p < 0.001). A multivariable logistic regression analysis examining admission and pre-cannulation laboratory and hemodynamic values demonstrated that lower pre-cannulation lactic acid levels predicted survival (OR 1.2, 95% CI 1.02-1.5, p = 0.03) with a significant inflection point of 7.4 mmol/L corresponding to decreased survival at hospital discharge. CONCLUSIONS Patients undergoing EVV did not have increased mortality compared to the overall trauma VV ECMO population. EVV resulted in ventilatory stabilization that allowed subsequent procedural treatment of injuries. LEVEL OF EVIDENCE Therapeutic Care/Management, IV.
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Affiliation(s)
| | | | - James K Webb
- Malcolm Grow Medical Clinics & Surgery Center, 1060 West Perimeter Road, Joint Base Andrews, MD 20762
| | - Rishi Kundi
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine 22 South Greene St, Baltimore, MD 21201
| | - Jody Cantu
- United States Air Force Material Command, 711th HPW En Route Care Medical Site, Baltimore, MD 21201
| | | | - James V O'Connor
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine 22 South Greene St, Baltimore, MD 21201
| | - Deborah M Stein
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine 22 South Greene St, Baltimore, MD 21201
| | - Matthew P Hanson
- Air Force Special Operations Command, Command Surgeon, Hurlburt Field, F 32544
| | - Bradley S Taylor
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD 21201
| | - Thomas M Scalea
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine 22 South Greene St, Baltimore, MD 21201
| | - Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, 22 South Greene St, Baltimore, MD 21201
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Chipman AM, Ottochian M, Ricaurte D, Gunter G, DuBose JJ, Stonko DP, Feliciano DV, Scalea TM, Morrison J. Contemporary management and time to revascularization in upper extremity arterial injury. Vascular 2023; 31:284-291. [PMID: 35418267 DOI: 10.1177/17085381211062726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Upper extremity arterial injury is associated with significant morbidity and mortality for trauma patients, but there is a paucity of data to guide the clinician in the management of these injuries. The goals of this review were to characterize the demographics, presentation, clinical management, and outcomes, and to evaluate how time to intervention associates with outcomes in trauma patients with upper extremity vascular injuries. METHODS The National Trauma Data Bank (NTDB) Research Data Set for the years 2007-2016 was queried in order to identify adult patients (age ≥ 18) with an upper extremity arterial injury. Patients with brachiocephalic, subclavian, axillary, or brachial artery injury using the 1998 and 2005 versions of the Abbreviated Injury Scale were included. Patients with non-survivable injuries to the brain, traumatic amputation, or other major arterial injuries to the torso or lower extremities were excluded. RESULTS The data from 7908 patients with upper extremity arterial injuries was reviewed. Of those, 5407 (68.4%) underwent repair of the injured artery. The median Injury Severity Score (ISS) was 10 (IQR = 7-18), and 7.7% of patients had a severe ISS (≥ 25). Median time to repair was 120 min (IQR = 60-240 min). Management was open repair in 52.3%, endovascular repair in 7.3%, and combined open and endovascular repairs in 8.8%; amputation occurred in 1.8% and non-operative management was used in 31.6% of patients. Blunt mechanism of injury, crush injury, concomitant fractures/dislocations, and nerve injuries were associated with amputation, whereas simultaneous venous injury was not. There was a significant decrease in the rate of amputation when patients undergoing surgical revascularization did so within 90 min of injury (P = 0.007). CONCLUSION Injuries to arteries of the upper extremity are managed with open repair, endovascular repair, and, rarely, amputation. Expeditious transport to the operating room for revascularization is the key for limb salvage.
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Affiliation(s)
- Amanda M Chipman
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Marcus Ottochian
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - Daniel Ricaurte
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Grahya Gunter
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joseph J DuBose
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - David P Stonko
- Department of Surgery, 160877Johns Hopkins Hospital, Baltimore, MD, United States
| | - David V Feliciano
- 12264University of Maryland School of Medicine, Baltimore, MD, United States
| | - Thomas M Scalea
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
| | - Jonathan Morrison
- 137889R. Adams Cowley Shock Trauma Center, 12264University of Maryland Medical System, Baltimore, Maryland, USA
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Harfouche MN, Dhillon NK, Hawley KL, DuBose JJ, Kozar RA, Feliciano DV, Scalea TM. Time to Splenic Angioembolization Does Not Impact Splenic Salvage Rates. Am Surg 2023:31348231161674. [PMID: 36878008 DOI: 10.1177/00031348231161674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
We aimed to determine whether early (<6 hours) vs delayed (≥6 hours) splenic angioembolization (SAE) after blunt splenic trauma (grades II-V) impacted splenic salvage rates at a level I trauma center (2016-2021). The primary outcome was delayed splenectomy by timing of SAE. Mean time of SAE was determined for those who failed vs those who had successful splenic salvage. We retrospectively identified 226 individuals, from which 76 (33.6%) were in the early group and 150 (66.4%) were in the delayed group. The early group had higher AAST grade, greater amount of hemoperitoneum on CT, and 3.9x greater odds of undergoing delayed splenectomy (P = .046). Time to embolization was shorter in the group that failed splenic salvage (5 vs 10 hours, P = .051). On multivariate analysis, timing of SAE had no effect on splenic salvage. This study supports performing SAE on an urgent rather than emergent basis in stable patients after blunt splenic injury.
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Affiliation(s)
- Melike N Harfouche
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Navpreet K Dhillon
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristy L Hawley
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joseph J DuBose
- Department of Surgery, Dell Medical School, 21976University of Texas at Austin, Austin, TX, USA
| | - Rosemary A Kozar
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - David V Feliciano
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas M Scalea
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
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Dhillon NK, Scalea TM. Common Injury Patterns in Trauma Patients Arriving in Extremis. Am Surg 2023:31348231157829. [PMID: 36803079 DOI: 10.1177/00031348231157829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Resuscitative thoracotomy (RT) may be utilized to obtain a perfusing rhythm, but identifying and treating bleeding immediately after successful RT is mandatory for survival. Trauma surgeons must be able to manage all injuries in these cases as there will likely not be enough time to obtain specialty consultation or to use endovascular management. We sought to determine common injuries in patients arriving in extremis and the injuries that require operative management. A retrospective review was conducted of all patients who underwent a RT at a high-volume Level 1 trauma center from 2010 to 2020. Those who had an autopsy report or lived to discharge were included in the study. High-grade cardiac, high-grade liver injuries, and pelvic fractures are commonly seen when trauma patients arrive in extremis and often require hemorrhage control. Trauma surgeons must be able to manage such injuries as obtaining specialty consultation or using endovascular therapy is not feasible.
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Affiliation(s)
- Navpreet K Dhillon
- R Adams Cowley Shock Trauma Center, 137889University of Maryland, Baltimore, MD, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, 137889University of Maryland, Baltimore, MD, USA
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27
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Hawley KL, Dhillon NK, DuBose JJ, Kozar RA, Scalea TM, Harfouche MN. Surveillance Imaging Associated With Delayed Splenectomy in High-Grade Blunt Splenic Trauma. Am Surg 2023:31348231157844. [PMID: 36802823 DOI: 10.1177/00031348231157844] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
This retrospective, single-site study at a level I trauma center (2016-2021) sought to determine whether repeat CT had an impact on clinical decision making after splenic angioembolization following blunt splenic trauma (grades II-V). The primary outcome was need for intervention after subsequent imaging (defined as angioembolization and/or splenectomy) by high- or low-grade injury. Of the 400 individuals examined, 78 (19.5%) underwent intervention after repeat CT, from which 17% were in the low-grade group (grades II and III) and 22% were in the high-grade group (grades IV and V). Individuals in the high-grade group were 3.6 times more likely to undergo delayed splenectomy than those in the low-grade group (P = .006). Delayed intervention after surveillance imaging in blunt splenic injury is driven mostly by the identification of new vascular lesions and leads to greater rates of splenectomy in high-grade injuries. Surveillance imaging should be considered for all AAST injury grades II or higher.
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Affiliation(s)
- Kristy L Hawley
- 137889R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Navpreet K Dhillon
- 137889R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Joseph J DuBose
- The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Rosemary A Kozar
- 137889R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Thomas M Scalea
- 137889R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Melike N Harfouche
- 137889R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
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Dave SB, Deatrick KB, Galvagno SM, Mazzeffi MA, Kaczorowski DJ, Madathil RJ, Rector R, Tabatabai A, Haase DJ, Herr D, Scalea TM, Menaker J. A descriptive evaluation of causes of death in venovenous extracorporeal membrane oxygenation. Perfusion 2023; 38:66-74. [PMID: 34365847 DOI: 10.1177/02676591211035938] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become an important support modality for patients with acute respiratory failure refractory to optimal medical therapy, such as low tidal volume mechanical ventilator support, early paralytic infusion, and early prone positioning. The objective of this cohort study was to investigate the causes and timing of in-hospital mortality in patients on VV ECMO. All patients, excluding trauma and bridge to lung transplant, admitted 8/2014-6/2019 to a specialty ICU for VV ECMO were reviewed. Two hundred twenty-five patients were included. In-hospital mortality was 24.4% (n = 55). Most non-survivors (46/55, 84%) died prior to lung recovery and decannulation from VV ECMO. Most common cause of death (COD) for patients who died on VV ECMO was removal of life sustaining therapy (LST) in setting of multisystem organ failure (MSOF) (n = 24). Nine patients died a median of 9 days [6, 11] after decannulation. Most common COD in these patients was palliative withdrawal of LST due to poor prognosis (n = 3). Non-survivors were older and had worse predictive mortality scores than survivors. We found that death in patients supported with VV ECMO in our study most often occurs prior to decannulation and lung recovery. This study demonstrated that the most common cause of death in patients supported with VV ECMO was removal of LST due MSOF. Acute hemorrhage (systemic or intracranial) was not found to be a common cause of death in our patient population.
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Affiliation(s)
- Sagar B Dave
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristopher B Deatrick
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samuel M Galvagno
- Department of Anesthesiology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael A Mazzeffi
- Department of Anesthesiology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ronson J Madathil
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Raymond Rector
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Ali Tabatabai
- Division of Pulmonary and Critical Care, Department of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J Haase
- Department of Emergency Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel Herr
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Thomas M Scalea
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jay Menaker
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA, USA
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Appelbaum RD, Esposito E, Spaulding MC, Simpson JP, Dunn J, Zier LB, Burruss S, Kim PP, Jacobson LE, Williams JM, Nahmias J, Grigorian A, Harmon L, Gergen AK, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Bugaev N, Tatar A, Zreik K, Lieser MJ, Stein DM, Scalea TM, Lauerman MH. Does treatment delay for blunt cerebrovascular injury affect stroke rate?: An EAST multicenter study. Injury 2022; 53:3702-3708. [PMID: 36085175 DOI: 10.1016/j.injury.2022.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to analyze injury characteristics and stroke rates between blunt cerebrovascular injury (BCVI) with delayed vs non-delayed medical therapy. We hypothesized there would be increased stroke formation with delayed medical therapy. METHODS This is a sub-analysis of a 16 center, prospective, observational trial on BCVI. Delayed medial therapy was defined as initiation >24 hours after admission. BCVI which did not receive medical therapy were excluded. Subgroups for injury presence were created using Abbreviated Injury Scale (AIS) score >0 for AIS categories. RESULTS 636 BCVI were included. Median time to first medical therapy was 62 hours in the delayed group and 11 hours in the non-delayed group (p < 0.001). The injury severity score (ISS) was greater in the delayed group (24.0 vs the non-delayed group 22.0, p < 0.001) as was the median AIS head score (2.0 vs 1.0, p < 0.001). The overall stroke rate was not different between the delayed vs non-delayed groups respectively (9.7% vs 9.5%, p = 1.00). Further evaluation of carotid vs vertebral artery injury showed no difference in stroke rate, 13.6% and 13.2%, p = 1.00 vs 7.3% and 6.5%, p = 0.84. Additionally, within all AIS categories there was no difference in stroke rate between delayed and non-delayed medical therapy (all N.S.), with AIS head >0 13.8% vs 9.2%, p = 0.20 and AIS spine >0 11.0% vs 9.3%, p = 0.63 respectively. CONCLUSIONS Modern BCVI therapy is administered early. BCVI with delayed therapy were more severely injured. However, a higher stroke rate was not seen with delayed therapy, even for BCVI with head or spine injuries. This data suggests with competing injuries or other clinical concerns there is not an increased stroke rate with necessary delays of medical treatment for BCVI.
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Affiliation(s)
| | - Emily Esposito
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Deborah M Stein
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | - Margaret H Lauerman
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
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30
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Bala M, Catena F, Kashuk J, De Simone B, Gomes CA, Weber D, Sartelli M, Coccolini F, Kluger Y, Abu-Zidan FM, Picetti E, Ansaloni L, Augustin G, Biffl WL, Ceresoli M, Chiara O, Chiarugi M, Coimbra R, Cui Y, Damaskos D, Di Saverio S, Galante JM, Khokha V, Kirkpatrick AW, Inaba K, Leppäniemi A, Litvin A, Peitzman AB, Shelat VG, Sugrue M, Tolonen M, Rizoli S, Sall I, Beka SG, Di Carlo I, Ten Broek R, Mircea C, Tebala G, Pisano M, van Goor H, Maier RV, Jeekel H, Civil I, Hecker A, Tan E, Soreide K, Lee MJ, Wani I, Bonavina L, Malangoni MA, Koike K, Velmahos GC, Fraga GP, Fette A, de'Angelis N, Balogh ZJ, Scalea TM, Sganga G, Kelly MD, Khan J, Stahel PF, Moore EE. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2022; 17:54. [PMID: 36261857 PMCID: PMC9580452 DOI: 10.1186/s13017-022-00443-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/17/2022] [Indexed: 02/08/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.
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Affiliation(s)
- Miklosh Bala
- Director of Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, POB 12000, 91120, Jerusalem, Israel.
| | - Fausto Catena
- General and Emergency Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Jeffry Kashuk
- Tel Aviv Sackler School of Medicine, Tel Aviv, Israel
| | - Belinda De Simone
- Department of General, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France
| | - Carlos Augusto Gomes
- Department of Surgery, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital Universitário Terezinha de Jesus, Juiz de Fora, Brazil
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | | | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Luca Ansaloni
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Marco Ceresoli
- Emergency and General Surgery Department, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Massimo Chiarugi
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- CECORC Research Center, Riverside University Health System, Loma Linda University, Loma Linda, USA
| | - Yunfeng Cui
- Department of Surgery, Nankai Clinical School of Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | | | - Salomone Di Saverio
- General Surgery Department Hospital of San Benedetto del Tronto, Marche region, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Michael Sugrue
- Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sandro Rizoli
- Surgery Department, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ibrahima Sall
- General Surgery Department, Military Teaching Hospital, Dakar, Senegal
| | | | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chirika Mircea
- Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Giovanni Tebala
- Department of Digestive and Emergency Surgery, S.Maria Hospital Trust, Terni, Italy
| | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald V Maier
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Hans Jeekel
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ian Civil
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andreas Hecker
- Emergency Medicine Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kjetil Soreide
- HPB Unit, Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Matthew J Lee
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Luigi Bonavina
- Department of Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
| | - Mark A Malangoni
- Case Western Reserve University School of Medicine, Cleveland, USA
| | | | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, PA, USA
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Andreas Fette
- Pediatric Surgery, Children's Care Center, SRH Klinikum Suhl, Suhl, Thueringen, Germany
| | - Nicola de'Angelis
- Unit of Digestive and HPB Surgery, Faculty of Medicine, University of Paris, Paris, France
| | - Zsolt J Balogh
- John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD, USA
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michael D Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Jim Khan
- University of Portsmouth, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Philip F Stahel
- College of Osteopathic Medicine, Rocky Vista University, Parker, CO, USA
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
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31
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Gauss T, Richards JE, Tortù C, Ageron FX, Hamada S, Josse J, Husson F, Harrois A, Scalea TM, Vivant V, Meaudre E, Morrison JJ, Galvagno S, Bouzat P. Association of Early Norepinephrine Administration With 24-Hour Mortality Among Patients With Blunt Trauma and Hemorrhagic Shock. JAMA Netw Open 2022; 5:e2234258. [PMID: 36205999 PMCID: PMC9547317 DOI: 10.1001/jamanetworkopen.2022.34258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
IMPORTANCE Hemorrhagic shock is a common cause of preventable death after injury. Vasopressor administration for patients with blunt trauma and hemorrhagic shock is often discouraged. OBJECTIVE To evaluate the association of early norepinephrine administration with 24-hour mortality among patients with blunt trauma and hemorrhagic shock. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter, observational cohort study used data from 3 registries in the US and France on all consecutive patients with blunt trauma from January 1, 2013, to December 31, 2018. Patients were alive on admission with hemorrhagic shock, defined by prehospital or admission systolic blood pressure less than 100 mm Hg and evidence of hemorrhage (ie, prehospital or resuscitation room transfusion of packed red blood cells, receipt of emergency treatment for hemorrhage control, transfusion of >10 units of packed red blood cells in the first 24 hours, or death from hemorrhage). Blunt trauma was defined as any exposure to nonpenetrating kinetic energy, collision, or deceleration. Statistical analysis was performed from January 15, 2021, to February 22, 2022. EXPOSURE Continuous administration of norepinephrine in the prehospital environment or resuscitation room prior to hemorrhage control, according to European guidelines. MAIN OUTCOMES AND MEASURES The primary outcome was 24-hour mortality, and the secondary outcome was in-hospital mortality. The average treatment effect (ATE) of early norepinephrine administration on 24-hour mortality was estimated according to the Rubin causal model. Inverse propensity score weighting and the doubly robust approach with 5 distinct analytical strategies were used to determine the ATE. RESULTS A total of 52 568 patients were screened for inclusion, and 2164 patients (1508 men [70%]; mean [SD] age, 46 [19] years; median Injury Severity Score, 29 [IQR, 17-36]) presented with acute hemorrhage and were included. A total of 1497 patients (69.1%) required emergency hemorrhage control, 128 (5.9%) received a prehospital transfusion of packed red blood cells, and 543 (25.0%) received a massive transfusion. Norepinephrine was administered to 1498 patients (69.2%). The 24-hour mortality rate was 17.8% (385 of 2164), and the in-hospital mortality rate was 35.6% (770 of 2164). None of the 5 analytical strategies suggested any statistically significant association between norepinephrine administration and 24-hour mortality, with ATEs ranging from -4.6 (95% CI, -11.9 to 2.7) to 2.1 (95% CI, -2.1 to 6.3), or between norepinephrine administration and in-hospital mortality, with ATEs ranging from -1.3 (95% CI, -9.5 to 6.9) to 5.3 (95% CI, -2.1 to 12.8). CONCLUSIONS AND RELEVANCE The findings of this study suggest that early norepinephrine infusion was not associated with 24-hour or in-hospital mortality among patients with blunt trauma and hemorrhagic shock. Randomized clinical trials that study the effect of early norepinephrine administration among patients with trauma and hypotension are warranted to further assess whether norepinephrine is safe for patients with hemorrhagic shock.
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Affiliation(s)
- Tobias Gauss
- Anesthesia and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Justin E. Richards
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | | | - François-Xavier Ageron
- Emergency Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sophie Hamada
- Department of Anesthesia and Critical Care, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris, Paris, France
- Centre de Recherche en épidémiologie et Santé des populations, INSERM U 10-18, Université Paris-Saclay, Paris, France
| | - Julie Josse
- National Institute for Research in Digital Science and Technology (INRIA), Montpellier, France
| | - François Husson
- Institut Agro, Université Rennes, French National Centre for Scientific Research, Institut de recherche mathématique de Rennes, Rennes, France
| | - Anatole Harrois
- Department of Anesthesiology and Critical Care, Bicêtre Hospital, AP-HP, University Paris Saclay, Le Kremlin Bicêtre, France
| | - Thomas M. Scalea
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | | | - Eric Meaudre
- Department of Intensive Care Unit and Anesthesia, Military Teaching Hospital Sainte-Anne, Toulon, France
| | - Jonathan J. Morrison
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Samue Galvagno
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Pierre Bouzat
- Anesthesia and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
- University Grenoble Alpes, INSERM, U1216, CHU Grenoble Alpes, Grenoble Institute Neurosciences, Grenoble, France
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Harfouche MN, Walton EC, Richardson JB, Scalea TM. Implementation of an Outpatient Violence Intervention Program to Increase Service Uptake. Prev Sci 2022; 24:535-540. [PMID: 36006598 PMCID: PMC9403958 DOI: 10.1007/s11121-022-01428-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/27/2022]
Abstract
Challenges in participant recruitment and retention limit the effectiveness of hospital-based violence intervention programs (HVIPs). This study aimed to determine if an outpatient violence intervention program (VIP) could be integrated into a trauma clinic and increase uptake of violence prevention services. Patients previously hospitalized for intent-to-harm being seen for outpatient follow-up were eligible. VIP counselors met with participants during their clinic visit, administered the survey, and offered violence prevention services (April to June 2019). Patients were followed for 6 months to assess involvement. The primary outcome of interest was long-term participation in the VIP, defined as uptake of services at 6 months, in comparison to inpatient recruitment. Out of 76 patients, 34 (44.7%) did not appear for their appointment. The remainder (n = 42) were offered participation in the study, of which 32 (76.2%) completed the survey. From the group offered VIP services, 57.1% expressed interest, and 5 (20.8%) ultimately took part yielding an overall participation rate of 11.9% at 6 months. The inpatient recruitment rate in 2019 was 2.4%. An outpatient VIP program can be integrated into a clinic setting but suffers from the same challenges faced by inpatient programs resulting in low rates of long-term participation in services. Although a high proportion of participants reported interest, actual engagement at 6 months was low. Reasons behind low participation in VIP services must be investigated.
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Affiliation(s)
- Melike N Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, 21201, USA.
| | - Erin C Walton
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, 21201, USA
- Center for Injury Prevention and Policy, University of Maryland Medical Center, Baltimore, MD, 21201, USA
| | - Joseph B Richardson
- University of Maryland, College Park, USA
- Department of African American Studies, University of Maryland, College Park, MD, 20742, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, 21201, USA
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Fernandez LG, Norwood SH, Orsi C, Heck M, Gonzalez K, Williams N, Matthews MR, Scalea TM, Swindall R. Use of a Modified ABTHERA ADVANCE™ Open Abdomen Dressing with Intrathoracic Negative-Pressure Therapy for Temporary Chest Closure After Damage Control Thoracotomy. Am J Case Rep 2022; 23:e937207. [PMID: 36153642 PMCID: PMC9520634 DOI: 10.12659/ajcr.937207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Case series
Patient: Male, 33-year-old • Male, 51-year-old
Final Diagnosis: Cardio thoracic trauma
Symptoms: Hemorrhagic shock
Medication: —
Clinical Procedure: Intrathoracic negative pressure therapy • thoracotomy
Specialty: Biotechnology • Cardiac Surgery • Critical Care Medicine • Surgery
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Affiliation(s)
| | | | - Carolina Orsi
- Department of Surgery, University of Texas Health Science Center, Tyler, USA, TX
| | - Marvin Heck
- Department of Surgery, University of Texas Health Science Center, Tyler, USA, TX
| | - Katherine Gonzalez
- School of Medicine, The University of Texas Medical Branch, Galveston, USA, TX
| | | | - Marc R. Matthews
- Burn Emergency Services, Respiratory Care Services, Arizona Burn Center, Maricopa Medical Center, University of Arizona College of Medicine, Phoenix, USA, AZ
| | - Thomas M. Scalea
- University of Maryland School of Medicine, University of Maryland Medical Center, Baltimore, USA, MD
| | - Rebecca Swindall
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center, Tyler, USA, TX
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Abdou H, Edwards J, Stonko D, Elansary N, Ottochian M, DuBose JJ, Scalea TM, Morrison JJ, Kundi R. The Role of Endovascular Repair of Popliteal Arterial Injuries in the Acute Setting. Ann Vasc Surg 2022; 87:522-528. [PMID: 35760265 DOI: 10.1016/j.avsg.2022.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/28/2022] [Accepted: 05/27/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES The role of endovascular surgery in the treatment of popliteal arterial injuries is not well established. As with other popliteal pathology, open repair has traditionally been considered the gold standard. As data has accumulated and technology advanced, however, a reassessment of the role of endovascular surgery is warranted. The aim of this study is to perform a noninferiority comparison of open versus endovascular management of traumatic popliteal injuries. Our hypothesis is that endovascular management is noninferior to open management of traumatic popliteal injuries. METHODS The National Trauma Data Bank was searched for adult patients from 2002-2016 for isolated popliteal arterial injury. The study used a standard noninferiority methodology to compare rates of amputation and compartment syndrome between endovascular and open surgery. Margins for noninferiority were established using established published rates of complications: 17.1% for amputations and 23.0% for compartment syndrome. Endovascular intervention would be considered noninferior to open surgery if the lower bound confidence of the complication proportion (endo/open complication rate) was greater than the pre-defined noninferiority margin. RESULTS 3698 patients met inclusion criteria, with blunt injury accounting for 2117 (57%) and penetrating injury accounting for 1581 (43%). Within the blunt group, 1976 (93.3%) underwent open and 141 (6.7%) endovascular surgery. The rate of compartment syndrome (percentage and 95% confidence interval) after surgery for open repair was 9.9 (8.6-11.2) and 6.4 (3.2-11.3) for endovascular repair. The complication proportion is 64.6 (59.7-69.5). The rate of amputation for open repair was 15.7 (14.2-17.4) and 14.2 (9.2-20.6) for endovascular repair. The complication proportion is 90.4 (87.4-93.4). Within the penetrating group, 1525 (96.5%) underwent open repair and 56 (3.5%) endovascular surgery. The rate of compartment syndrome after surgery for open repair was 14.9 (13.2-16.7) and 5.4 (1.5-13.6) for endovascular repair. The complication proportion is 36.2 (31.3-41.1). The rate of amputation for open repair was 4.3 (3.3-5.4) and 3.6 (0.7-11.0) for endovascular repair. The complication proportion is 83.7 (75.3-90.6). CONCLUSION These data suggest that endovascular repair of popliteal artery injury may be noninferior to open repair with respect to limb preservation . Further examination of endovascular repair in popliteal artery injury is warranted.
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Affiliation(s)
- Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Joseph Edwards
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - David Stonko
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Marcus Ottochian
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD.
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD
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Jinadasa SP, Mueller AL, Apffel A, Cave B, DuBose JJ, Scalea TM, Kundi R. Close surveillance imaging is unnecessary for patients with grade I blunt thoracic aortic injury. Am J Surg 2022; 224:1324-1328. [PMID: 35728986 DOI: 10.1016/j.amjsurg.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/31/2022] [Accepted: 06/07/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND No evidence-based recommendations exist for imaging surveillance of grade I blunt thoracic aortic injuries (BTAI). We aimed to evaluate the natural history of these injuries to provide guidance for follow-up imaging. METHODS Patients that presented to our trauma center from 2008 to 2021 with grade I BTAI were retrospectively evaluated. CT angiography images were assessed for initial injury grade and subsequent stability, improvement, worsening, or resolution. RESULTS Of 83 patients who had grade I injuries and repeat imaging, 57.8% had complete resolution, 20.5% had improvement, and 18.1% had stability of their injury. Only seven patients (8.4%) demonstrated worsening of their injury. Six patients had eventual resolution and one underwent endovascular repair that would not have been performed under current practice patterns. CONCLUSIONS Since grade I injuries do not worsen to require later surgical intervention, early surveillance imaging is not necessary and further imaging may not be necessary at all.
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Affiliation(s)
- Sayuri P Jinadasa
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201, USA.
| | - Ariel L Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Annie Apffel
- University of Maryland School of Medicine, 655 W Baltimore Street, Baltimore, MD, 21201, USA.
| | - Brandon Cave
- University of Maryland School of Medicine, 655 W Baltimore Street, Baltimore, MD, 21201, USA.
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201, USA.
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201, USA.
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201, USA.
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Treffalls RN, Poe K, Abdou H, Stonko DP, Edwards J, Ptak T, White JM, Scalea TM, Morrison JJ. Utilization of Intra-Arterial Contrast for Computed Tomography Aortography in a Swine Model. JVS Vasc Sci 2022. [DOI: 10.1016/j.jvssci.2022.05.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Madurska MJ, Abdou H, Elansary NN, Edwards J, Patel N, Stonko DP, Richmond MJ, Scalea TM, Rasmussen TE, Morrison JJ. Whole Blood Selective Aortic Arch Perfusion for Exsanguination Cardiac Arrest: Assessing Myocardial Tolerance to the Duration of Cardiac Arrest. Shock 2022; 57:243-250. [PMID: 35759304 DOI: 10.1097/shk.0000000000001946] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Selective aortic arch perfusion (SAAP) is an endovascular technique that consists of aortic occlusion with perfusion of the coronary and cerebral circulation. It been shown to facilitate return of spontaneous circulation (ROSC) after exanguination cardiac arrest (ECA), but it is not known how long arrest may last before the myocardium can no longer be durably recovered. The aim of this study is to assess the myocardial tolerance to exsanguination cardiac arrest before successful ROSC with SAAP. METHODS Male adult swine (n = 24) were anesthetized, instrumented, and hemorrhaged to arrest. Animals were randomized into three groups: 5, 10, and 15 min of cardiac arrest before resuscitation with SAAP. Following ROSC, animals were observed for 60 min in a critical care environment. Primary outcomes were ROSC, and survival at 1-h post-ROSC. RESULTS Shorter cardiac arrest time was associated with higher ROSC rate and better 1-h survival. ROSC was obtained for 100% (8/8) of the 5-min ECA group, 75% (6/8) of the 10-min group, 43% (3/7) of the 15-min group (P = 0.04). One-hour post-ROSC survival was 75%, 50%, and 14% in 5-, 10-, and 15-min groups, respectively (P = 0.02). One-hour survivors in the 5-min group required less norepinephrine (1.31 mg ± 0.83 mg) compared with 10-SAAP (0.76 mg ± 0.24 mg), P = 0.008. CONCLUSION Whole blood SAAP can accomplish ROSC at high rates even after 10 min of unsupported cardiac arrest secondary to hemorrhage, with some viability beyond to 15 min. This is promising as a tool for ECA, but requires additional optimization and clinical trials.Animal Use Protocol, IACUC: 0919015.
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Affiliation(s)
- Marta J Madurska
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
- Henry-Jackson Foundation, Bethesda, Maryland
| | - Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Noha N Elansary
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Neerav Patel
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - David P Stonko
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
- Henry-Jackson Foundation, Bethesda, Maryland
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael J Richmond
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
- Henry-Jackson Foundation, Bethesda, Maryland
| | - Thomas M Scalea
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Todd E Rasmussen
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jonathan J Morrison
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
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Abdou H, Edwards J, Patel N, Stonko DP, Elansary N, Lang E, Richmond MJ, Ptak T, White JM, Scalea TM, Morrison JJ. Characterizing Brain Perfusion in a Swine Model of Raised Intracranial Pressure. J Surg Res 2022; 278:64-69. [PMID: 35594616 DOI: 10.1016/j.jss.2022.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/18/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Perfusion of the brain is critical, but this can be compromised due to focal space occupying lesions (SOL). SOLs can raise intracranial pressure (ICP), resulting in reduced cerebral blood flow (CBF). Most gyrencephalic models of brain injury focus on parenchymal injury, with few models of acutely elevated ICP. We hypothesized that we could employ a SOL technique to develop a titratable ICP model and sought to quantitate the resulting decrease in brain perfusion. METHODS Six swine were anesthetized and instrumented. A Fogarty balloon catheter was inserted intracranially. Blood CO2 partial pressure was maintained between 35 and 45 mmHg. The Fogarty balloon was infused with normal saline at 1 mL/min to ICP targets of 10, 20, 30, and 40 mmHg. CBF (mL/100 g/min) were assessed at each ICP level using computed tomography perfusion (CTP). Data are presented as the mean ± standard deviation with all pressures measured in mmHg. CBF values were compared between baseline and each ICP level using analysis of variance. RESULTS Baseline ICP was 5 ± 2 and systolic blood pressure was 106 ± 7. Balloon volumes (mL) required to achieve each incremental ICP level were 2.4 ± 0.5, 4.9 ± 1.7, 7.6 ± 1.6, and 9.9 ± 1.7. CBF decreased with each raised ICP level, with CBF being significantly less than baseline at ICP values of 30 (56.1 ± 34.7 versus 20.6 ± 11.0, P < 0.05) and 40 (56.1 ± 34.7 versus 6.5 ± 10.6, P < 0.05). CONCLUSIONS An intracranial balloon catheter can be used to increase ICP, delivering a proportionate reduction in CBF. This model can be used in the future studies to examine adjuncts that manipulate intracranial pressure and their effect on brain perfusion.
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Affiliation(s)
- Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Joseph Edwards
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Neerav Patel
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - David P Stonko
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Eric Lang
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Michael J Richmond
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Thomas Ptak
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Joseph M White
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland.
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Canakis A, Kesar V, Hudspath C, Kim RE, Scalea TM, Darwin P. Intraoperative endoscopic retrograde cholangiopancreatography for traumatic pancreatic ductal injuries: Two case reports. World J Gastrointest Endosc 2022; 14:342-350. [PMID: 35719898 PMCID: PMC9157699 DOI: 10.4253/wjge.v14.i5.342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/09/2022] [Accepted: 04/15/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In order to successfully manage traumatic pancreatic duct (PD) leaks, early diagnosis and operative management is paramount in reducing morbidity and mortality. In the acute setting, endoscopic retrograde cholangiopancreatography (ERCP) can be a useful, adjunctive modality during exploratory laparotomy. ERCP with sphincterotomy and stent placement improves preferential drainage in the setting of injury, allowing the pancreatic leak to properly heal. However, data in this acute setting is limited. CASE SUMMARY In this case series, a 27-year-old male and 16-year-old female presented with PD leaks secondary to a gunshot wound and blunt abdominal trauma, respectively. Both underwent intraoperative ERCP within an average of 5.9 h from time of presentation. A sphincterotomy and plastic pancreatic stent placement was performed with a 100% technical and clinical success. There were no associated immediate or long-term complications. Following discharge, both patients underwent repeat ERCP for stent removal with resolution of ductal injury. CONCLUSION These experiences further demonstrated that widespread adaption and optimal timing of ERCP may improve outcomes in trauma centers.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Varun Kesar
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Caleb Hudspath
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Raymond E Kim
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Thomas M Scalea
- Department of Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Peter Darwin
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
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Treffalls RN, Poe K, Abdou H, Stonko DP, Edwards J, Ptak T, White JM, Scalea TM, Morrison JJ. Abstract 289: Utilization Of Intra-Arterial Contrast For Computed Tomography Aortography In A Swine Model. Arterioscler Thromb Vasc Biol 2022. [DOI: 10.1161/atvb.42.suppl_1.289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background:
Intraoperative computed tomography (CT) imaging with endovascular catheter delivery of intra-arterial (IA) contrast could potentially provide higher signal attenuation in directed anatomic locations with lower contrast volumes. We compared image quality and attenuation timing of IA versus IV contrast protocols for abdominal imaging.
Methods:
Five anesthetized swine had internal jugular access and ascending aortic pigtails placed percutaneously via the brachial artery. The IV contrast protocol utilized 100 mL of iodinated contrast at 5 mL/sec over 20/sec. The IA protocol delivered 50 mL at 5 mL/sec over 10/sec. A 16-slice CT scanner with a 10 mm detector acquired static serial images at 1 image/second for 45 secs. Region-of-interest markers were used to select the aorta and portal vein to capture arterial and venous attenuation via Hounsfield Units (HU) per second. Attenuation curves were assessed using a Pearson’s correlation. Adequate attenuation was defined as >100 HU a priori and image quality assessed using Contrast-to-Noise Ratio (CNR).
Results:
Both contrast protocols achieved adequate image attenuation with an aortic peak of 665 ± 226 (Mean HU ± SD) for IA and 414 ± 141 for IV. IA contrast achieved faster peak aortic attenuation compared to IV contrast [8 vs 20 sec; p<0.001] (Fig 1). Portal values (attenuation and time to peak) were similar for IA vs IV: [146 ± 46 vs 169 ± 39; 34 vs 42 sec; p<0.05]. IA administration achieved a superior CNR in less time compared to IV [10 vs 23 sec; p<0.001]. All curves were modeled using non-linear least squares regression and achieved an R
2
>0.94; p<0.001.
Conclusion:
IA contrast achieves adequate opacification and a superior CNR compared to IV contrast, while using a smaller volume for intraoperative directed imaging. The incorporation of intraoperative CT with IA contrast could radically change imaging protocols for endovascular aortic repair.
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Affiliation(s)
| | - Kelly Poe
- R. Adams Cowley Shock Trauma Cntr, Univ of Maryland, Baltimore, MD
| | - Hossam Abdou
- R. Adams Cowley Shock Trauma Cntr, Univ of Maryland, Baltimore, MD
| | | | - Joseph Edwards
- R. Adams Cowley Shock Trauma Cntr, Univ of Maryland, Baltimore, MD
| | - Thomas Ptak
- R. Adams Cowley Shock Trauma Cntr, Univ of Maryland, Baltimore, MD
| | | | - Thomas M Scalea
- R. Adams Cowley Shock Trauma Cntr, Univ of Maryland, Baltimore, MD
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Lauerman M, Esposito E, Spalding C, Simpson J, Dunn JA, Zier L, Burruss S, Kim P, Jacobson LE, Williams J, Nahmias J, Grigorian A, Harmon L, Gergen A, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Appelbaum R, Bugaev N, Tatar A, Zreik K, Lieser MJ, Scalea TM, Stein DM. Endovascular Intervention in Internal Carotid Artery Blunt Cerebrovascular Injury: An EAST Multicenter Study. Am Surg 2022; 88:1962-1969. [PMID: 35437020 DOI: 10.1177/00031348221078958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Use of endovascular intervention (EI) for blunt cerebrovascular injury (BCVI) is without consensus guidelines. Rates of EI use and radiographic characteristics of BCVI undergoing EI nationally are unknown. METHODS A post-hoc analysis of a prospective, observational study at 16 U.S. trauma centers from 2018 to 2020 was conducted. Internal carotid artery (ICA) BCVI was included. The primary outcome was EI use. Multivariable logistic regression was performed for predictors of EI use. RESULTS From 332 ICA BCVI included, 21 (6.3%) underwent EI. 0/145 (0%) grade 1, 8/101 (7.9%) grade 2, 12/51 (23.5%) grade 3, and 1/20 (5.0%) grade 4 ICA BCVI underwent EI. Stroke occurred in 6/21 (28.6%) ICA BCVI undergoing EI and in 33/311 (10.6%) not undergoing EI (P = .03), with all strokes with EI use occurring prior to or at the same time as EI. Percentage of luminal stenosis (37.75 vs 20.29%, P = .01) and median pseudoaneurysm size (9.00 mm vs 3.00 mm, P = .01) were greater in ICA BCVI undergoing EI. On logistic regression, only pseudoaneurysm size was associated with EI (odds ratio 1.205, 95% CI 1.035-1.404, P = .02). Of the 8 grade 2 ICA BCVI undergoing EI, 3/8 were grade 2 and 5/8 were grade 3 prior to EI. Of the 12 grade 3 ICA BCVI undergoing EI, 11/12 were grade 3 and 1/12 was a grade 2 ICA BCVI prior to EI. DISCUSSION Pseudoaneurysm size is associated with use of EI for ICA BCVI. Stroke is more common in ICA BCVI with EI but did not occur after EI use.
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Affiliation(s)
- Margaret Lauerman
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Esposito
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Joshua Simpson
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Linda Zier
- University of Colorado, Loveland, CO, USA
| | | | - Paul Kim
- 4608Loma Linda University, Loma Linda, CA, USA
| | | | | | | | | | | | | | | | | | - Andrew J Young
- 14640Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jose L Pascual
- 14640Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | - Rovinder S Sandhu
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rachel Appelbaum
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nikolay Bugaev
- 1867Tufts University School of Medicine, Boston, MA, USA
| | - Antony Tatar
- 1867Tufts University School of Medicine, Boston, MA, USA
| | | | | | - Thomas M Scalea
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah M Stein
- 137889R Adams Cowley Shock Trauma Center at University of Maryland School of Medicine, Baltimore, MD, USA
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Abstract
We investigated whether the COVID-19 pandemic affected rates of interpersonal
violence (IV). A retrospective study was performed using city-wide crime data
and the trauma registry at one high-volume trauma center pre-pandemic [PP]
(March-October 2019) and during the pandemic [PA] (March-October 2020). The
proportion of trauma admissions attributable to IV remained unchanged from PP to
PA, but IV increased as a proportion of overall crime (34% to 41%, p<0.001).
Assaults decreased, but there was a proportionate increase in penetrating trauma
which was mostly attributable to firearms. Despite a reduction in admissions due
to IV in the first 4 months of the pandemic, the rates of violence subsequently
exceeded that of the same months in 2019. The cause of the observed increase of
IV is multi-factorial. Future studies aimed at identifying the root causes are
essential to mitigate violence during this ongoing health crisis.
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Affiliation(s)
| | | | | | - Jose J Diaz
- 12264University of Maryland Medical Center, Baltimore, MA, USA
| | - Thomas M Scalea
- 137889R Adams Cowley Shock Trauma Center, Baltimore, MA, USA
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Laverty RB, Treffalls RN, McEntire SE, DuBose JJ, Morrison JJ, Scalea TM, Moore LJ, Podbielski JM, Inaba K, Piccinini A, Kauvar DS. Life over limb: Arterial access-related limb ischemic complications in 48-hour REBOA survivors. J Trauma Acute Care Surg 2022; 92:723-728. [PMID: 34789696 DOI: 10.1097/ta.0000000000003440] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used in some trauma settings. Arterial access-related limb ischemic complications (ARLICs) resulting from the femoral arterial access required for REBOA are largely under reported. We sought to describe the incidence of these complications and the clinical, technical, and device factors associated with their development. METHODS This was a retrospective cohort study of records of adult trauma patients from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute care surgery registry between October 2013 and September 2020 who had REBOA and survived at least 48 hours. The primary outcome was ARLIC, defined as clinically relevant extremity ischemia or distal embolization. Relevant factors associated with ARLIC were also analyzed. RESULTS Of 418 identified patients, 36 (8.6%) sustained at least one ARLIC; 22 with extremity ischemia, 25 with distal embolism, 11 with both. Patient demographics and injury characteristics were similar between ARLIC and no ARLIC groups. Access-related limb ischemic complication was associated with larger profile devices (p = 0.009), cutdown access technique (p = 0.02), and the presence of a pelvic external fixator/binder (p = 0.01). Patients with ARLIC had higher base deficit (p = 0.03) and lactate (p = 0.006). One hundred fifty-six patients received tranexamic acid (TXA), with 22 (14%) ARLICs. The rate of TXA use among ARLIC patients was 61% (vs. 35% TXA for non-ARLIC patients, p = 0.002). Access-related limb ischemic complication did not result in additional in-hospital mortality, however, ARLIC had prolonged hospital LOS (31 vs. 24 days, p = 0.02). Five ARLIC required surgical intervention, three patch angioplasty (and two with associated bypass), and four ARLIC limbs were amputated. CONCLUSION Femoral artery REBOA access carries a risk of ARLIC, which is associated with unstable pelvis fractures, severe shock, and strongly with the administration of TXA. Use of lower-profile devices and close surveillance for these complications is warranted in these settings and caution should be exercised when using TXA in conjunction with REBOA. LEVEL OF EVIDENCE Prognostic and Epidemiologic, Level III.
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Affiliation(s)
- Robert B Laverty
- From the Department of Surgery (R.B.L.), Brooke Army Medical Center, JBSA Fort Sam Houston, Houston; Department of Surgery, University of the Incarnate Word School of Medicine (R.N.T.), San Antonio; Department of Surgery, Vascular Surgery Service (S.E.M., D.S.K.), Brooke Army Medical Center, JBSA Fort Sam Houston, Houston, Texas; Department of Surgery, University of Maryland/R Adams Cowley Shock Trauma Center (J.J.D., J.J.M., T.M.S.), Baltimore, Maryland; Department of Surgery, University of Texas Health Sciences Center-Houston (L.J.M., J.M.P.), Houston, Texas; Department of Surgery, Los Angeles County + University of Southern California Hospital (K.I., A.P.), Los Angeles, California; and Department of Surgery (D.S.K.), Uniformed Services University, Bethesda, Maryland
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Scalea TM. Caring for vascular injuries: Training more vascular specialists may not be the answer. J Trauma Acute Care Surg 2022; 92:760-761. [PMID: 35045058 DOI: 10.1097/ta.0000000000003526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Harfouche MN, Madurska MJ, Elansary N, Abdou H, Lang E, DuBose JJ, Kundi R, Feliciano DV, Scalea TM, Morrison JJ. Resuscitative endovascular balloon occlusion of the aorta associated with improved survival in hemorrhagic shock. PLoS One 2022; 17:e0265778. [PMID: 35324991 PMCID: PMC8947416 DOI: 10.1371/journal.pone.0265778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is controversial as a hemorrhage control adjunct due to lack of data with a suitable control group. We aimed to determine outcomes of trauma patients in shock undergoing REBOA versus no-REBOA. Methods This single-center, retrospective, matched cohort study analyzed patients ≥16 years in hemorrhagic shock without cardiac arrest (2000–2019). REBOA (R; 2015–2019) patients were propensity matched 2:1 to historic (H; 2000–2012) and contemporary (C; 2013–2019) groups. In-hospital mortality and 30-day survival were analyzed using chi-squared and log rank testing, respectively. Results A total of 102,481 patients were included (R = 57, C = 88,545, H = 13,879). Propensity scores were assigned using age, race, mechanism, lowest systolic blood pressure, lowest Glasgow Coma Score (GCS), and body region Abbreviated Injury Scale scores to generate matched groups (R = 57, C = 114, H = 114). In-hospital mortality was significantly lower in the REBOA group (19.3%) compared to the contemporary (35.1%; p = 0.024) and historic (44.7%; p = 0.001) groups. 30-day survival was significantly higher in the REBOA versus no-REBOA groups. Conclusion In a high-volume center where its use is part of a coordinated hemorrhage control strategy, REBOA is associated with improved survival in patients with noncompressible torso hemorrhage.
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Affiliation(s)
- Melike N. Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
- * E-mail:
| | | | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Eric Lang
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Joseph J. DuBose
- Dell Medical School, University of Texas at Austin, Austin, Texas, United States of America
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - David V. Feliciano
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Thomas M. Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Jonathan J. Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
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Smyth L, Bendinelli C, Lee N, Reeds MG, Loh EJ, Amico F, Balogh ZJ, Di Saverio S, Weber D, Ten Broek RP, Abu-Zidan FM, Campanelli G, Beka SG, Chiarugi M, Shelat VG, Tan E, Moore E, Bonavina L, Latifi R, Hecker A, Khan J, Coimbra R, Tebala GD, Søreide K, Wani I, Inaba K, Kirkpatrick AW, Koike K, Sganga G, Biffl WL, Chiara O, Scalea TM, Fraga GP, Peitzman AB, Catena F. WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment. World J Emerg Surg 2022; 17:13. [PMID: 35246190 PMCID: PMC8896237 DOI: 10.1186/s13017-022-00418-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/26/2022] [Indexed: 02/08/2023] Open
Abstract
The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.
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Affiliation(s)
- Luke Smyth
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Cino Bendinelli
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.
| | - Nicholas Lee
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Matthew G Reeds
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Eu Jhin Loh
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Francesco Amico
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Dieter Weber
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Fikri M Abu-Zidan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Solomon Gurmu Beka
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Massimo Chiarugi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Vishal G Shelat
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Edward Tan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Ernest Moore
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Luigi Bonavina
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Rifat Latifi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andreas Hecker
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Jim Khan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Raul Coimbra
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Giovanni D Tebala
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kjetil Søreide
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Imtiaz Wani
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kenji Inaba
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Kaoru Koike
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Gabriele Sganga
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Walter L Biffl
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Osvaldo Chiara
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Gustavo P Fraga
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew B Peitzman
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Fausto Catena
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
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Esposito EC, Kufera JA, Wolff TW, Spalding MC, Simpson J, Dunn JA, Zier L, Burruss S, Kim P, Jacobson LE, Williams J, Nahmias J, Grigorian A, Harmon L, Gergen A, Chatoor M, Rattan R, Young AJ, Pascual JL, Murry J, Ong AW, Muller A, Sandhu RS, Appelbaum R, Bugaev N, Tatar A, Zreik K, Hustad L, Lieser MJ, Stein DM, Scalea TM, Lauerman MH. Factors associated with stroke formation in blunt cerebrovascular injury: An EAST multicenter study. J Trauma Acute Care Surg 2022; 92:347-354. [PMID: 34739003 DOI: 10.1097/ta.0000000000003455] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Stroke risk factors after blunt cerebrovascular injury (BCVI) are ill-defined. We hypothesized that factors associated with stroke for BCVI would include medical therapy (i.e., Aspirin), radiographic features, and protocolization of care. METHODS An Eastern Association for the Surgery of Trauma-sponsored, 16-center, prospective, observational trial was undertaken. Stroke risk factors were analyzed individually for vertebral artery (VA) and internal carotid artery (ICA) BCVI. Blunt cerebrovascular injuries were graded on the standard 1 to 5 scale. Data were from the initial hospitalization only. RESULTS Seven hundred seventy-seven BCVIs were included. Stroke rate was 8.9% for all BCVIs, with an 11.7% rate of stroke for ICA BCVI and a 6.7% rate for VA BCVI. Use of a management protocol (p = 0.01), management by the trauma service (p = 0.04), antiplatelet therapy over the hospital stay (p < 0.001), and Aspirin therapy specifically over the hospital stay (p < 0.001) were more common in ICA BCVI without stroke compared with those with stroke. Antiplatelet therapy over the hospital stay (p < 0.001) and Aspirin therapy over the hospital stay (p < 0.001) were more common in VA BCVI without stroke than with stroke. Percentage luminal stenosis was higher in both ICA BCVI (p = 0.002) and VA BCVI (p < 0.001) with stroke. Decrease in percentage luminal stenosis (p < 0.001), resolution of intraluminal thrombus (p = 0.003), and new intraluminal thrombus (p = 0.001) were more common in ICA BCVI with stroke than without, while resolution of intraluminal thrombus (p = 0.03) and new intraluminal thrombus (p = 0.01) were more common in VA BCVI with stroke than without. CONCLUSION Protocol-driven management by the trauma service, antiplatelet therapy (specifically Aspirin), and lower percentage luminal stenosis were associated with lower stroke rates, while resolution and development of intraluminal thrombus were associated with higher stroke rates. Further research will be needed to incorporate these risk factors into lesion specific BCVI management. LEVEL OF EVIDENCE Prognostic and Epidemiologic, Level IV.
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Affiliation(s)
- Emily C Esposito
- From the University of Maryland School of Medicine (E.E., J.A.K., T.M.S., M.H.L.), Baltimore, Maryland; Ohio State University Wexner Medical Center (T.W.W., M.C.S., A.J.Y.), Columbus, Ohio; Greenville Health System (J.S.), Greenville, South Carolina; University of Colorado (J.A.D., L.Z., La.H., An.G.), Boulder, Colorado; Loma Linda University (S.B., P.K.)., Loma Linda, California; Ascension Health (L.E.J., J.W.), St. Louis, Missouri; University of California (J.N., Ar.G.), Oakland, California; University of Miami (M.C., R.R.), Miami, Florida; Perelman School of Medicine at the University of Pennsylvania (J.L.P.), Philadelphia, Pennsylvania; UT Health Tyler (J.M.), Tyler, Texas; Towerhealth (A.W.O., A.M.), West Reading, Pennsylvania; Lehigh Valley Health Network (R.S.S., R.A.), Allentown, Pennsylvania; Tufts University School of Medicine (N.B., A.T.), Boston, Massachusetts; Sanford Health (K.Z., Le.H.), Sioux Falls, South Dakota; Research Medical Center (M.J.L.), Kansas City, Missouri; University of California San Francisco (D.M.S.), San Francisco, California
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48
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Affiliation(s)
- Sayuri P Jinadasa
- From the R Adams Cowley Shock Trauma Center (S.P.J., J.J.D., R.K., T.M.S., J.J.M.) and Division of Interventional Radiology (J.F.S.), University of Maryland Medical System, Baltimore, Maryland
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Abstract
BACKGROUND Associated injuries are thought to increase mortality in patients with severe abdominopelvic trauma. This study aimed to identify clinical factors contributing to increased mortality in patients with severe abdominopelvic trauma, with the hypothesis that a greater number of concomitant injuries would result in increased mortality. METHODS This was a retrospective review of the Trauma Quality Improvement Program (TQIP) database of patients ≥ 18 years with severe abdominopelvic trauma defined as having an abdominal Abbreviated Injury Score (AIS) ≥ 3 with pelvic fractures and/or iliac vessel injury (2015-2017). Primary outcome was in-hospital mortality based on concomitant body region injuries. Secondary outcomes included mortality at 6 h, 6 to 24 h, and after 24 h based on concomitant injuries, procedures performed, and transfusion requirements. RESULTS A total of 185,257 patients were included in this study. Survivors had more severely injured body regions than non-survivors (4 vs. 3, P < 0.001). Among those who died within 6 h, 28.5% of patients required a thoracic procedure and 43% required laparotomy compared to 6.3% and 22.1% among those who died after 24 h (P < 0.001). Head AIS ≥ 3 was the only body region that significantly contributed to overall mortality (OR 1.26, P < 0.001) along with laparotomy (OR 3.02, P < 0.001), neurosurgical procedures (2.82, P < 0.001) and thoracic procedures (2.28, P < 0.001). Non-survivors who died in < 6 h and 6-24 h had greater pRBC requirements than those who died after 24 h (15.5 and 19.5 vs. 8 units, P < 0.001). CONCLUSION Increased number of body regions injured does not contribute to greater mortality. Uncontrolled noncompressible torso hemorrhage rather than the burden of concomitant injuries is the major contributor to the high mortality associated with severe abdominopelvic injury.
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Affiliation(s)
- Neerav Patel
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Melike Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - David P Stonko
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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Edwards J, Abdou H, Patel N, Lang E, Richmond MJ, Rasmussen TE, Scalea TM, Morrison JJ. Open chest selective aortic arch perfusion vs open cardiac massage as a means of perfusion during in exsanguination cardiac arrest: a comparison of coronary hemodynamics in swine. Eur J Trauma Emerg Surg 2022; 48:2089-2096. [PMID: 34984495 DOI: 10.1007/s00068-021-01810-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/25/2021] [Indexed: 11/29/2022]
Abstract
AIM To describe and compare the aortic-right atrial pressure (AoP-RAP) gradients and mean coronary perfusion pressures (CPPs) generated during open chest selective aortic arch perfusion (OCSAAP) with those generated during open cardiac massage (OCM) in hypovolemic swine. METHODS Ten male Hanford swine utilized in a prior poly-trauma study were included in the study. Animals were rendered hypovolemic via a 30% volume bleed. Upon confirmation of death, animals underwent immediate clamshell thoracotomy and aortic cross-clamping followed by 5 min of OCM. A catheter suitable for OCSAAP was then inserted into the aorta and animals underwent 1 min of OCSAAP at a rate of 10 mL/kg/min. Aortic and right atrial pressures were recorded continuously using solid-state blood pressure catheters. Representative 10-s intervals from each resuscitation method were extracted. Hemodynamic parameters including AoP-RAP gradients and CPPs were calculated and compared. RESULTS At baseline, time from death to intervention was significantly shorter for OCM. However, mean CPPs and AoP-RAP gradients were significantly higher in animals undergoing OCSAAP. 98% of OCSAAP segments had a mean CPP > 15, compared to 35% of OCM intervals. While OCM had a significant negative correlation between time to intervention and maximum CPP, this correlation was not significant for OCSAAP. CONCLUSION OCSAAP generates favorable and potentially time-resistant pressure gradients when compared to those generated by OCM. Further investigation of the technique of OCSAAP is warranted, as it may have potential utility as a therapy during resuscitative thoracotomy (RT).
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Affiliation(s)
- Joseph Edwards
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Hossam Abdou
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Neerav Patel
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Eric Lang
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Michael J Richmond
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Todd E Rasmussen
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Thomas M Scalea
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Jonathan J Morrison
- Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA.
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